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0 <br />ATTACHMENT A - ACCIDENT REPORT FORM <br />This form is required by Public Law 91-596 and must be kept <br />in the establishments for 5 years. Failure to maintain can <br />result in the issuance of citations and assessment of <br />penalties. <br />Location of Office: <br />1 _ Name <br />2. Mail address (No. and street, city or town, State, and zip code) <br />3. Location if different from mail address <br />Injured or Ill Employee <br />4. Name (First, middle, and last) Social Security No. <br />of File No. <br />5. Home address (No. and street, city or town, State, and zip code) <br />6. Age 17. Sex (Check one) Male o Female <br />8. occupation (Enter regular job title, not the specific activity he was performing at <br />time of injury.) <br />9. 'Department (Enter name of department of division in which the injured person is <br />regularly employed, even though he may have been temporarily working in another <br />department at the time of injury.) <br />The Accident or Exposure to Occupational Illness <br />If accident or exposure occurred on employer's premises, give address of plant or <br />establishment in which it occurred. Do not indicate department or division within the plant <br />or establishment. If accident occurred outside employer's premises at an identifiable <br />address, give that address. If it occurred on a public highway or at any other place which <br />cannot be identified by number and street, please provide place references locating the <br />place of injury as accurately as possible. <br />10. Place of accident or exposure (No. And street, city or town, State and zip code) <br />11. Was place of accident or exposure on employer's premises? Yes o No o <br />12. What was the employee doing when injured? (Be specific. if he was using tools or <br />equipment or handling material, name them and tell what he was doing with them.) <br />