California Employer's Report of Occupational Injury Or Illness
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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

OSHA CASE NO.

FATALITY
Any person who makes or causes to be made any
knowingly false or fraudulent material statement or
material representation for the purpose of obtaining or
denying workers compensation benefits or payments is
guilty 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 the
date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or
illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness, or death
must be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.

1. FIRM NAME

Ia.