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FORM D - Employee Report of Injury or Illness State of California SAN JOAQUIN COUNTY EMPLOYER'S REPORT RISKMANAGEMENT OF OCCUPATIONAL 44 N SAN JOAQUIN ST.,SUITE 330 INJURY OR ILLNESS STOCKTON CA 95202 NOTICE:California law re{}rVes employers to report within FIVE DAYS of knowledge every occupational injury or illness - which results in lost Cline beyond the date of the incident or requires medical treatment beyond first aid.If an employee - subsequently des as a result of a previously reported injury or illness,the employer must file within FIVE DAYS of or denying workers* compensation benefits or knowledge an amended report indicating death. In addition, every serious injuryfillness, or death must be reported payments is guilty of a felony. IMMEDIATELY telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health. i.FIRM NAME SAN INUIN COUNTY IV 2.MAILING ADDRESS(Number and Street.City.Zip) L 3.NATURE OF BUSINESS,e 9,painting contractor,wholesale grocer,hotel,etc 4.STATE UNEMPLOYMENT INSURANCE ACCT.NO. COUNTY DOVE WENT 5.DEPARTMENT 5A HOME DEPARTMENT CODE 6.TYPE OF EMPLOYER ❑Private []State ❑City ®County ❑School District ❑Other-Government-Specify:_ 7.EMPLOYEE NAME 7A SOCIAL SECURITY NUMBER 6 EMPLOYEE ID NUMBER 9.HOME ADDRESS Nurnow and Street) 9B.HOME PHONE NUMBER 10.DATE OF BIRTH(m.%W) 9A.CITY,STATE,ZIP it.SEX ❑Male ❑Female 12.OCCUPATION(Payrdl Title) 12AL TITLE CODE 13 DATE OF HIRE(mmrorM L 14 EMPLOYEE USUALLY WORKS HOURS PER DAY DAYS PER WEEK TOTAL WEEKLY HOURS 14A.EMPLOYMENT STATUS(Check apphoatrie status at time of uyury) 14B.Does the employee accrue sick leave? ❑REGULAR FULL-TIME ❑PART-TIME ❑TEMPORARY _OTHER ❑YES ❑NO 15.GROSS WAGES/SALARY 15A.OTHER PAYMENTS NOT REPORTED AS WAG ESISALARY(e g.tpg meals,lodging,overtrne,bonuses,elc I $ per (hrorwk) ❑ YES.$ per ❑ NO 16.SUPERVISORS NAM i6A.SU VI 'S -MAIL 16B.SUPERVISORS PHONE 16C.EMPLOYEE'S WORK PHONE 17,DATE OF INJURY OR ONSET OF ILLNESS(mm/dvyr? 18.TIME INJURY/ILLNESS OCCURRED 19 TIME EMPLOYEE BEGAN WORK 20,F EMPLOYEE DIEDDATE OFDEATH AM. PM, AM. PM (mMtlNY,? 21.UNABLE TO WORK FOR AT LEAST ONE FULL Y 22 DATt LASTWUHKtU bnao WfA 23. A RE FURNM3K(h"'Vol ) 24 LL K, ❑ PFfER DOTE OF INJURY? OYES ❑NO CHECKTHISBOX 25,PAFULL WAGES FOR DAY OF INJJ Y SALARY BE NO OF EMPLOYERS KNOWLEDG 28.DATE EMPLOYEE W PROVIDED EMPLOYEE CONTINUED? NOTICE OF NJURYALLNESS(min'06W) CLAIM FORM (hvry o" J LAST DAY WORKED? ❑YES ❑NO ❑YES ❑NO 29.SPECIFIC INJURYALLNESS AND PART OF BODY AFFECTED,MEDICAL DIAGNOSIS,(e q,second degree bumsoo light arm,fendonArsnf bIt elbow,kad pownng) 30 LOCA ION WHERE V N O SU U (Strael, uadirg, ) 30A COUNTY 3 NEMPLOYE 'S REMISES% SAN 'TOAQUIN COUNTY ❑YES ❑NO 31.DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED(e.g shpping daparbhen(machine mp,mom numba-' OTHER WORKERS INJURE ALL IN THIS EVENT? ❑YES ❑NO 33.EQUIPMENT.MATERIALS AND CHEMICALS THEEMPLOYEE WAS USING W-I OR EXPOSURE 071JR-RED I.g,aw yene,welding tomb,rarm bailor,scaflM L L 34.WHAT WAS EMPLOYEE DOING WHEN THE INJURY/LLNESS Occurred.e.g.,weldng warns of metal forms.loading boxes onto truck,biting binders. 35.HOW INJJRYILLNESS OCCURRED.DESCRIBE SEQUENCE OF EVENTS.SPECIFY OBJECTOR EXPOSURE WHICH DIRECTLY PRODUCED THE INJJRYALLNESS(e.g.waken stepped back to inspect work end sipped on sc,ap malerel.As he feI,he brusTed against heat well,and burned rghthand).(SPACE WILL EXPAND TO ACCOMMODATE YOUR DESCRPT IOri 36.NAME AND CITY OF PHYSICIAN WHO TREATED EMPLOYEE FOR THIS INJURY 36a.PHONE NUMBER 3T F HOSPITALIZED AS AN INPATIENT,NAME AND CITY OF HOSPITAL 38 PHONE NUMBER 39.DEPARTMENT REPRESENTATIVE WHO COMPLETED THIS FORM 1 40 EMPLOYER COMMENTS(space wia expand) Dale Name: Phone: ORM e- 20 x FILING THIS REPORT IS NOT AN ADMISSION OF LIABILITY San Joaquin County Department of Public Works County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e 28