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Classification Employer's Report of ❑Lost Workday OSHA Case Occupational Injury or ❑ LW Restricted Duty or File No. Illness ❑ OSHA Medical ❑ first Aid Every work injury to an employee which causes disability lasting longer than the day of the injury or which requires medical services other than first aid treatment must be reported within live days aher the in jury.If the injury results in death,a report must he made by telephone or telegraph to the Home Office not later than 24 hours after death. A.RM.Rcvd. E 1.Firm Name Location Cade Co. DepL Div. Loc. M Chevron Research Company (GO-75 A) Please do not P 2.Mailin Address(Please include city,ZIP) B.Acrif-type L P.$, Box 1627, Richmond, California 94802 use this column o 3.Location,if different from Mail Address G Entity Co. y Case No. E 4.Nature of Business le. .Mfg,Mktg,Mktg OP,EL&P,Research,Finance) 5.State Unemployment Insurance Acct.Number N Petroleum 'tesearch 004-7678-8 D.Prop.Dam. 6.Name Employer No. 7.Sao Security Number If 6.Home Address(number and street,city,ZIP( Industry E.Proddos E M S.Sex 10.Dccupanan(regular job title,not specific activity at time of injuryl 11.Date of Birth Sex F.End Date P 0 Male ❑female L onth ay ear 0 12.Department in which regularly employed 12A.Date of Hire Age G.End Time y Month Do Year E Type Employee: 12B.How long in present job? E X Regular ❑Seasonal ❑Casual ❑ Part Time Less than 3 mos._ 3 mos.to 6 mos.- Occupation H.Investigate 6 mos.to 2 yrs. _ Over 2 yrs. 13.Gross Wages/Salary Weekly Wage Employee Earns$ Per ❑Hour ❑ Day ❑Week Cl Every Two Weeks ❑ Month I./-Wines 14.Where did accident or exposure occur?Inumber one street,cityl 14A.County 15.On Employer's premises? Yes O No County 16.What was Employee doing when injured?(Please he specific.Identify tools,equipment or material the employee was using) J.t Injured Accident Type K.SI.I-Loc. Agency L.S1:2.Loc, N J 17.How did the accident or exposure occur?(Please describe fully the events that resulted in injury or occupational disease.Tell what happened and how it happened. Agency Part U Please use separate sheet it necessaryl M.51:3toc. A Supplemental y Agency N.S1:4 La. 0 Nature of Injury D.SL SLas. R 18.Object or substance that directly injured Employee le.g.the machine employee struck against or which struck him;the vapor or poison inhaled or swallowed;the - chemical that irritated his skin;incases of strains,the thing he was liking,pulling,etc.) Part of Body P.Coded by L Injury Date L 19A.Describe the injury ar illness le.g.cut,strain,fracture,skin rash,eta) 19B.Part of body affected le.g.back,leh wrist,right eye,etc.) N U' E Extent of Injury 20.Name and address of Physician 21.If hospitalized,name and address of hospital S Code _ _ _ - - Cade _ _ _ _ _ q, S 22.Date of injury or illness 23.Time of day 24.Did employee lose at least one full day's work after the injury? Insurance Carrier I I a.m. Month Day Year P m ❑Yes,first date absent Month I No S. 25.Hes Em to ee Day Year P V ❑Regular work ❑Restricted work 26.Did Employee tlie? Report Lag returned to work? ❑Yes,date returned I I ❑Yes,date r I )(I No ❑No,still aH work Month Day Year Month Day Year 27.Date Employer notified of injury 26.To whom reported 29.Names of witnesses Coded By I Month Day Year Reviewed by(name of Manager reviewing reportl Title Date Filing of This Report is Not an Admission of Liability