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ATTACHMENT B <br /> ACCIDENT REPORT FORM <br /> Fassessment <br /> required by Public Law 91-596 and must be Case of File No. <br /> establishments for 5 years. Failure to <br /> n result in the issuance of citations and <br /> of enalties. <br /> Office: <br /> Mail address (No. and street, city or town, State, and zip code) <br /> ' Location if different from mail address <br /> d or III Em Employee <br /> 4. Name (First, middle, and last) Social Securi No. <br /> S. Home address No. and street city or town State, and zip code <br /> 6. A e 7. Sex Check one Male ❑ Female ❑ <br /> 8. Occupation (Enter regular job title, not the specific activity he was performing at time <br /> ' of injury.) <br /> rdepartm:entatt <br /> ent (Enter name of department of division in which the injured person is <br /> ularloyed, even though he may have been temporarily working in another <br /> 1 ire time of injury.) <br /> 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 or <br /> establishment. If accident occurred outside employer's premises at an identifiable address, <br /> give that address. If it occurred on a public highway or at any other place which cannot be <br /> identified by number and street, please provide place references locating the place of injury as <br /> 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 remises? Yes ❑ No ❑ <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 /> 902 Industrial Way•Lodi,CA 95240•209.367.3701 •Fax 209.333.8303 132014 Neil O.Anderson&Associates,Inc. <br />