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Elding seams of metal forms, loading boxes onto truck. County 26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURY/ILLNESS, 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. Nature of Injury 27a. Phone Number 27. NAME AND ADDRESS OF PHYSICIAN (Number, Street, City, Zip) 28. HOSPITALIZED AS AN INPATIEN.

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20a Related content

  • The Supervisor's Role in - CalHR - CA.gov

    Employer's Report of Occupational Injury or Illness e3067 (REV. 8/10). This fillable form...

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