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1 • <br /> Appendix A: CAL/OSHA Form 301 <br /> Information about the employee <br /> ' Full name: <br /> Address: <br /> Date of birth: <br /> Date hired: <br /> Male: ❑ Female: ❑ <br /> Information about the physician or other health care professional <br /> t Name of physician or other health care <br /> professional <br /> If treatment was given away from the <br /> ' worksite where was itgiven? <br /> Facility: <br /> Address: <br /> Was employee treated in an emergency <br /> Yes: ❑ No: <br /> room? ❑ <br /> ' Was employee hospitalized overnight as Yes: ❑ No: ❑ <br /> an in-patient? <br /> ' Information about the case <br /> Case number from the log (Transfer the case <br /> number from the Log after you record the <br /> case. <br /> Date of injury or illness: <br /> Time employee began work: AM: PM: <br /> Time of event: AM: PM: <br /> ' Check if time cannot be determined: <br /> What was the employee doing just before the incident occurred? <br /> ' Describe the activity, as well as the tools, equipment, or material the employee was using. Be <br /> specific. <br /> Examples."climbing a ladder while carrying roofing materials";"spraying chlorine from hand sprayer"; "daily <br /> computer key-entry.' <br /> AEI Health&Safety,Injury&Illness Prevention Plan <br /> March 15,2012 <br /> 1 <br />