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Classification Employer's Report of 0 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 after the in jury.It the injury results in death,a report must be made by telephone or telegraph to the Home Office not later than 24 hours after death. A.Apt.III E 1.Firm Name Location Code Co. Dept Div. Loc. M Chevron Research Company IGD-76 Al - - - - - - - p 2.Mailin Address Please include city,ZIP( Please do not a.Amid.-Type L P. . Box 1627, Richmond, California 94802 use this column o 3.Location,if different from Mail Address y Case No. C.Emity{d. E 4.Nature of Business(e. Mfg,Mktg,Mktg OP,EL&P,Research,Finance) 5.State Unemployment Insurance Acct.Number R Petroleum .� esearch 004-7678-8 Employer No. 0.Prop.Dam. 6.Name 7.Social Security Number ndustry 8.Home Address Inumber and street,city,ZIPI E.Prod:Loa E IH 9. Sex 10.Occupation(regular job title,not specific activity at time of injuryl 11.Date of Binh L L Sex F.End Date ❑Male 11Female omla--fi- Oa- Yesr L12.Department in which regularly employed 12A.Date of Hire I Age G.Endiime y Month Da Year E Type Employee: 128.Haw long in present joh? 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 ❑ Every Two Weeks ❑ Month I.I-wainm 14.Where did accident or exposure occur?Inumber and street,city) 14A.County 15.On Employers premises? - Yes ❑ No County 16.What was Employee doing when injured?IPlease be specific.Identify tools,equipment or material the employee was using) J.I Injured Accident Type K.SI:1{a. Agency 1 I.SI:2 Loc. N Agency Part J 17.How did the accident or exposure occur?IPlease describe fully the events that resulted in injury or occupational disease.Tell what happened and haw it happened. Please use separate sheet if necessary) M.SI:3ioo. L) R Supplemental y Agency N.SI.4-Loc. O Nature of Injury 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 pan of 0.SI:Sla. chemical that irritated his skin;in rases of strains,the thing he was liking,pulling,etc.) -Body P.Coded-by L Injury Data L 19A.Describe the injury or illness(e.g.cut,strain,fracture,skin(ash,etc.) 19B.Pan of body affected le.g.back,left wrist,right eye,etc) N D. EExtent of Injury 20.Name and address of Physician 21.If hospitalaed,name and address at hospital S Code - - _ _ _ Code - - _ - - B. 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 a.m. I I ❑Yes,first date absent f I 11No Month Day Year p.m. Month Day Year S. 25.Has Employee ❑Regular work ❑Restricted work 26.Did Employee die? Report lag returned to work? ❑Yes,date returned I 1 ❑Yes,date I 1 )1 No ❑No,still off work Month Oa Year Month Day Year Coded By T 27.Date Employer notified of injury 28.To whom reported 29.Names of witnesses I I Month Day Year Reviewed by(name of Manager reviewing noon) Title Date Filing of This Report is Not an Admission of liability