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Instructions For Filling Out This Form

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State of California Please complete in triplicate (type if possible) Mail two copies to:EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS

Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony.

California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury orillness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness, or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.

EMPLOYER

6. TYPE OF EMPLOYER:City School DistrictPrivate CountyState Other Gov't, Specify:

17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OFINJURY/ILLNESS (mm/dd/yy)

18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM15. PAID FULL DAYS WAGES FOR DATE OF SEX16. SALARY BEING CONTINUED?NJURY OR LAST FORM (mm/dd/yy)Yes NoDAY WORKED? Yes No19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS if available, e.g.. Second degree burns on right arm, tendonitis on left elbow, lead poisoning AGE

INJURY

21. ON EMPLOYER'S PREMISES?20a. COUNTY20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip)

Yes No

22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop. 23. Other Workers injured or ill in this event?Yes No

OR

ILLNESS

PART OF BODY

ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes. See CCR Title 8 14300.29 (b)(6)-(10) & 14300.35(b)(2)(E)2.Note: Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2*.

EMPLOYEE

35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)

37b. UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED

37a. EMPLOYMENT STATUS37. EMPLOYEE USUALLY WORKSregular, full-time part-time

EXTENT OF INJURY

total weekly hoursdays per week,hours per day,temporary seasonal

39. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, overtime, bonuses, etc.)?38. GROSS WAGES/SALARYper$ Yes No

Date (mm/dd/yy)Signature & TitleCompleted By (type or print)

Confidential information may be disclosed only to the employee, former employee, or their personal representative (CCR Title 8 14300.35), to others for the purpose of processing a workers' compensation or other insuranceclaim; and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 14300.30). CCR Title 8 14300.40 requires provision upon request to certain state and.federal workplace safety agencies.

FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY

OSHA CASE NO.

FATALITY

1. FIRM NAME Ia. Policy Number

2. MAILING ADDRESS: (Number, Street, City, Zip) 2a. Phone Number

3. LOCATION if different from Mailing Address (Number, Street, City and Zip) 3a. Location Code

4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc. 5. State unemployment insurance acct.no

Please do not usethis column

CASE NUMBER

OWNERSHIP

INDUSTRY

OCCUPATION7. DATE OF INJURY / ONSET OF ILLNESS(mm/dd/yy)

8. TIME INJURY/ILLNESS OCCURREDPMAM

9. TIME EMPLOYEE BEGAN WORKPMAM

10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy)

1 1. UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY?

Yes No

12. DATE LAST WORKED (mm/dd/yy) 13. DATE RETURNED TO WORK (mm/dd/yy) 14. IF STILL OFF WORK, CHECK THIS BOX:

DAILY HOURS

DAYS PER WEEK

WEEKLY HOURS

WEEKLY WAGE

COUNTY

NATURE OF INJURY

24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold

25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Welding seams of metal forms, loading boxes onto truck.

26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS, e.g.. Worker stepped back to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY

SOURCE

EVENT

SECONDARY SOURCE

http://.be/

Elsa Q Gomez

pmaiNATURE OF INJURY27. Name and address of physician (number, street, city, zip) 27a. Phone Number

pmai

Accident Investigation Forms

City of Los Angeles Personnel Department

Accident investigation forms/statements consist of the Employees Report of Injury, Accident Witness Statement, and Supervisors Accident Investigation. The supervisor should provide these to the appropriate individuals for completion after any accident or near miss incident that could have resulted in an accident. Other reports or forms may be acceptable substitutes, as long as they provide the same information (i.e. Use of force investigation, traffic accident investigation).

IMPORTANT - Obtaining signed statements as soon as possible following an accident insures that the employer has an accurate account of how the injury occurred, helps correct hazards to prevent the accident from recurring, and assures the employees claim is documented.

After I have these forms completed, what do I do with them? 1. For all accidents or near miss incidents (regardless of the outcome): the supervisor should complete any

corrective actions identified during the investigation to prevent recurrence of the incident and document this on the Supervisors Accident Investigation form. The supervisor should also keep copies of all the forms for future reference.

2. For all accidents that result in the employee filing a workers compensation claim: in addition to step 1 above, submit a copy of these forms to the Workers Compensation Division along with the Employers Report of Occupational Injury or Illness (Form 5020) and the Workers Compensation Claim Form (DWC 1) to the Personnel Department Workers Compensation Division. Form 5020 and DWC 1 can be obtained on the Citys intranet at:

http://cityweb.ci.la.ca.us/repository/forms/urldisplay.cfm?id=70

http://cityweb.ci.la.ca.us/repository/forms/urldisplay.cfm?id=486

Workers Compensation Division 700 E. Temple Street, Room 210 Los Angeles, CA 90012 Mail Stop 391 Fax: (213) 473-3333 Email: per.wcdiv@lacity.org

3. For accidents that result in a fatality or a serious injury (i.e. loss of a member of the body/amputation, in-patient hospitalization in excess of 24 hours for other than observation, or a serious degree of permanent disfigurement like crushing or severe burns): in addition to steps 1 and 2 above, the supervisor must notify the nearest Cal-OSHA District office within 8 hours. For a list of the Cal-OSHA District offices phone numbers and detailed instructions for reporting serious injuries, please go to the links provided below:

http://www.dir.ca.gov/asp/DoshZipSearch.html

http://per.lacity.org/safety/safety_page.htm

What if my injured employee is physically unable to fill out the Employees Report of Injury? Use common sense and good judgment. If the injury is severe, remember that your employees health and care are first and foremost. If possible, have the form filled out at a later, more appropriate time when the employee is physically able to document the accident.

What if my employee refuses to fill out or sign an Employees Report of Injury? Of course, you cannot make an employee fill out the document. You can however stress the importance of getting their account of the accident to help prevent the injury from happening again. Also, still obtain the supervisor's report as well as any witness statements.

http://cityweb.ci.la.ca.us/repository/forms/urldisplay.cfm?id=70http://cityweb.ci.la.ca.us/repository/forms/urldisplay.cfm?id=486mailto:per.wcdiv@lacity.orghttp://www.dir.ca.gov/asp/DoshZipSearch.html

2

Employee's Report of Injury Form (To complete by the employee)

Employee's name: _________________________________________________________Male Female Date of birth: ___________ Home telephone # ______________________________________ Home address: _____________________________________________________________________________ Present classification: _______________________________________________________________________ Location of accident:________________________________________________________________________ Date of accident: ______________________________________Time of accident: _______AM__________PM Describe fully how accident occurred: (including events that occurred immediately before the accident):

_________________________________________________________________________________________

Describe bodily injury sustained (be specific about body part(s) affected):

_________________________________________________________________________________________

Recommendation on how to prevent this accident from recurring

_________________________________________________________________________________________

_________________________________________________________________________________________

Name of supervisor: _________________________________________________ Phone#_________________ Name(s) of witness(es): ______________________________________________ Phone#_________________ When did you report the accident to your supervisor? ______________________________________________

Who did you report the injury to?______________________________________________________________ Do you require medical attention? Yes:_______ No:_______ Maybe:__________ Signature of employee: ________________________________ Date:________________

3

Accident Witness Statement Form (To be completed by Accident Witness)

Injured employee's name: ____________________________________________________________________ Name of witness: ______________________________________________ Phone # _____________________ Job title of witness: _________________________________________________________________________ Home address of witness: _________________________________________________________________________________________ Location of accident: ________________________________________________________________________ Date of accident: _____________________________________ Time of accident: ________AM________PM Describe fully how accident occurred: (including events that occurred immediately before the accident): Describe bodily injury sustained (be specific about body part(s) affected): Recommendation on how to prevent this accident from recurring: ____________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Name of Witnesses Supervisor: _________________________________________ Phone #_______________ Signature of Witness: _________________________________________________ Date: ________________

4

Supervisor's Accident Investigation Form (To be completed by the employee's supervisor or other responsible administrative official)

Injured employee name Employer's Premises: Yes No

Job site: Yes No

Date of accident or illness:

Location where accident occurred

Employee

Non-Employee

Time of accident ___________ am __________ pm

Job title or occupation Name of dept. normally assigned How long has employee worked at job where injury or illness occurred?

What property/equipment was damaged?

Property/equipment owned by:

What was employee doing when injury/illness occurred? What machine or tool was being used? What type of operation?

How did injury/illness occur? List all objects and substances involved.

Part of body affected/injured? Any prior physical conditions? If so, what? Yes No

Nature and extent of injury/illness and property damaged (be specific)

PLEASE INDICATE ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS Lack of training or skill Unsafe condition/act Equipment use (unsafe or lack of)

Failure to follow procedures/protocols Use of force incident Traffic accident

Work environment/exposure Repetitive work Fitness/Training

Supervisor's corrective action to ensure this type of accident does not recur:

Was employee trained in the appropriate use of Personal Protective Equipment/Proper safety procedures? Yes No

Was employee cautioned for failure to use Personal Protective Equipment/Proper safety procedures? Yes No

Did employee promptly report the injury/illness? Yes No

Is there modified duty available? Yes No

Supervisors name Supervisors Signature Phone # Date

Revise date : 20160517

Please_complete_in_tripli: CITY OF LOS ANGELES PERSONNEL DEPARTMENT 700 EAST TEMPLE STREET, ROOM 210 LOS ANGELES, CA 90012OSHA_CASE_NO: CheckBox1: 6: 11: 18I_PAID_FULL_DAYS_WAGES_FO: 29: 36_DATE_OF_H_RE_mmiddlyy: E: hours_per_day: days_per_week1: 37a: 37b-under-chat-class-code: FillText1: per: 39: 27: 27. Name and address of physician (number, street, city, zip)27a: 27a. Phone Number28: 28. Hospitalized as an inpatient overnight?28yes_text: If yes then, name and address of hospital (number, street, city, zip)28no: No28yes: Yes29yes: Yes29no: No29text: 29. Employee treated in emergency room?28a: 28a. Phone Number30: 30. EMPLOYEE NAME31: 31. SOCIAL SECURITY NUMBER32: 32. DATE OF BIRTH (mm/dd/yy)33: 33. HOME ADDRESS (Number, Street, City,Zip)33a: 33a. PHONE NUMBER36: 36. DATE OF HIRE (mm/dd/yy)34sex: 34. SEX34male: Male34female: FemaleName of witness: Phone_3: Job title of witness: Recommendation on how to prevent this accident from recurring 3: Recommendation on how to prevent this accident from recurring 2: Name of Witnesses Supervisor: Phone_4: Date_2: Text7: txt_employeename: txt_birthday: txt_employeeaddress: txt_occupation: txt_injurylocation: txt_injurydate: txt_injurtam: txt_injurypm: txt_injuryactivity: txt_injurypart: Home address of witness: Other_Govt_Specify: 20a_COUNTY: 1: 2: 16_SALARY_BEING_CONTINUED: 22_DEPARTMENT_WHERE_EVENT: 24_EQUIPMENT_MATERIALS_AN: 23: txt_injuryhow: 27_name _address_of_physician: 27_Phone_411h: 29_HOSP_TA_ZED_AS_AN_NAl: Jills_Phone_No: 31_SOC_A_SECUPITi_NUMBER: Completed_By_type_or_prin: Name of supervisor: Phone: Names of witnesses: Phone_2: Who did you report the injury to: Date: 1_FIRM_NAME: 2_MAILING_ADDRESS_Number: 3_LOCATION_ifdifferent_fr: 4_NATURE_OF_BUSINESS_eg_P: 2a_Phone_Number: 7_DATE_OF_INJURY__ONSET_1: AM1: 10_IF_EMPLOYEE_DIED_DATE: 12_DATE_RETURNED_TO_WORK: 13_DATE_RETURNED_TO_WORK: Check Box009: txt_dateinjurynotice: 18_DATE_EMPLOYEE_PROVIDED: Text1: Self InsuredText3: N/Atxt_phone: Name of dept normally assigned: What propertyequipment was damaged: Propertyequipment owned by: Radio Button6: Radio Button7: Radio Button8: Radio Button2: sex: attention_requirement: Injured employee name: Date of accident or illness: Location where accident occurred: Job title or occupation: How long has employee worked at job where injury or illness occurred: Supervisors corrective action to ensure this type of accident does not recur: Supervisors name: Date_3: Phone_5: Supervisors Signature: Radio Button1: Radio Button4: Radio Button9: Radio Button3: lack of training: failure to follow: work environment: unsafe: use of force: repetitive work: falty equipment: traffic: fitness: txt_injurypart_ext: