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form 3067: Employer's Report of Occupational Injury or Illness Call…
Tags: california division, california law, california osha, compensation insurance fund, division of occupational safety and health, first aid, free fax, fund representative, health state, information notice, injury report, insurance, medical treatment, occupational safety and health, osha case, reporting center, state compensation insurance, state compensation insurance fund, state of california, telegraph,Pages: 2
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Created: Mon Nov 7 11:07:47 2005
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form 3067:
Employer's Report of
Occupational Injury or Illness
Call State Fund's 24-hour Claims Reporting Center
toll-free at (888) 222-3211 to file your report. A State
Fund representative will complete the report with you
over the phone and mail you a copy.
Alternatively, you may fax your injury report to our
toll-free fax line at (800)371-5905. If you choose this
method, retain a copy of the report for your records.
A State Fund representative will contact you for
additional information.
NOTICE: 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.
State of California OSHA
Case No.
EMPLOYER'S REPORT STATE COMPENSATION INSURANCE FUND
OF OCCUPATIONAL 24-Hour Claims Reporting Center
INJURY OR ILLNESS Telephone: (888) 222-3211 Fax (800) 371-5905
Fatality
Any person who makes or causes to be made any NOTICE: California law requires employers to report within five days of knowledge every occupational injury or illness
knowingly false or fraudulent material statement which results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. If an employee
or material representation for the purpose of subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge
obtaining or denying workers' compensation an amended report indicating death. In addition, every serious injury, illness, or death must be reported immediately by
benefits or payments is guilty of a felony. telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.
1. FIRM NAME DIVISION 1a. Policy Number Please do
not use this
Column
E 2. MAILING ADDRESS (Number and Street, City, Zip) 2a. Phone Number Case Number
M
P Ownership
3. LOCATION, if different from Mailing Address (Number, Street, City and Zip) 3a. Location Code
L
O
Y 4. NATURE OF BUSINESS; e.g., Painting contractor, wholesale grocer, sawmill, hotel, etc. 4a. NUMBER OF EMPLOYEE ON 5. STATE UNEMPLOYMENT INSURANCE Industry
E THIS DOI ACCT. NO.
R Occupation
6. TYPE OF EMPLOYER
PRIVATE STATE COUNTY CITY SCHOOL DIST. OTHER GOVERNMENT - SPECIFY ____________________________________
7. DATE OF INJURY / ONSET OF ILLNESS 8. TIME INJURY/ILLNESS OCCURRED 9. TIME EMPLOYEE BEGAN WORK 10. IF EMPLOYEE DIED, DATE OF DEATH Sex
(mm/dd/yy) (mm/dd/yy)
________ A.M. ________ P.M. ________ A.M. ________ P.M.
11. UNABLE TO WORK FOR AT LEAST ONE 12. DATE LAST WORKED (mm/dd/yy) 13. DATE RETURNED TO WORK 14. IF STILL OFF WORK, CHECK THIS Age
FULL DAY AFTER (mm/dd/yy) BOX
YES NO
DATE OF INJURY?
15. PAID FULL DAY'S WAGES FOR DATE OF 16. SALARY BEING CONTINUED? 17. DATE OF EMPLOYER'S KNOWLEDGE/ 18. DATE EMPLOYEE WAS PROVIDED Daily hours
I INJURY OR LAST NOTICE OF INJURY/ILLNESS (mm/dd/yy) CLAIM FORM (mm/dd/yy)
YES NO YES NO
N DAY WORKED?
J 19. SPECIFIC INJURY/ILLNESS AND MEDICAL DIAGNOSIS if available, e.g., Second degree burns on right arm, tendonitis on left elbow, lead poisoning. 19a. BODY PART AFFECTED Days per Week
U
R 20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Address) 20a. ZIP 20b. COUNTY 21. ON EMPLOYER'S PREMISES? 21a. WAS ANOTHER PERSON
Y RESPONSIBLE? Weekly Hours
YES NO YES NO
22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g., Shipping department, machine shop. 23. OTHER WORKERS INJURED OR ILL IN THIS EVENT?
O
R YES NO Weekly Wage
24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g., Acetylene, welding torch, farm tractor, scaffold.
I
L 25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g., Welding seams of metal forms, loading boxes onto truck. County
L
N
E 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.
S Nature of Injury
S
27. NAME AND ADDRESS OF PHYSICIAN (Number, Street, City, Zip) 27a. Phone Number
28. HOSPITALIZED AS AN INPATIENT OVERNIGHT? NO YES If yes, then, NAME AND ADDRESS OF HOSPITAL (Number, 28a. Phone Number Part of body
Street, City, Zip) (Number, Street, City, Zip)
29. Employee treated in Emergency Room?
YES NO
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 possible while
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. Source
Note: Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2.*
30. EMPLOYEE NAME 31. SOCIAL SECURITY NUMBER 32. DATE OF BIRTH (mm/dd/yy)
Event
E 33. HOME ADDRESS (Number, Street, City, Zip) 33a. PHONE NUMBER
M
P 34. SEX 35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers) 36. DATE OF HIRE (mm/dd/yy) Secondary
L Source
O MALE FEMALE
Y 37. EMPLOYEE USUALLY WORKS 37a. EMPLOYMENT STATUS disabled unemployed 37b. UNDER WHAT CLASS CODE OF YOUR
POLICY WERE WAGES ASSIGNED?
E hours days total
regular, full-time part-time retired on strike Extent of Injury
E ______per day ________per week _________weekly hours temporary seasonal laid-off other
38. GROSS WAGES/SALARY 39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g., tips, meals, overtime,
bonuses, etc.)?
$ ___________________ per ___________________ YES NO
Completed By (type or print) Signature & Title Date (mm/dd/yy)
* 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 insurance claim: 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.
SCIF e3067 (REV. 9-05) FILING OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY. A CLAIM FORM MUST BE GIVEN TO THE INJURED WORKER WITHIN ONE
WORKING DAY OF YOUR KNOWLEDGE OF OCCUPATIONAL INJURY OR ILLNESS WHICH RESULTS IN LOST TIME OR MEDICAL TREATMENT.