5020 Employer's Report of Occupational Injury or Illness

Date of Report(Required)

OSHA CASE NO.

EE#(Required)

Employee SSN#(Required)

Employee DOB(Required)

Employee Date of Hire(Required)

Employee Name(Required)

First Last

Employee Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employee Occupation(Required)

Employee Phone(Required)

Sex?(Required)

Male

Female

Employment Status(Required)

Regular, Full Time

Part Time

Temporary

Seasonal

Time EE Began Work (AM only)

Time EE Began Work (PM only)

Days Worked per Week(Required)

Hours Worked per Day(Required)

Wage Class Code(Required)

Gross Wage/Salary(Required)

Paid per(hour/day/week)?(Required)

Other Payments Not Reported as Wages/Salary? (e.g. Tips, meals, overtime, bonuses, etc)(Required)

Yes

No

Was EE Treated in the EMERGENCY ROOM?(Required)

Yes

No

Name of Treating Physician(Required)

Phone of Physician(Required)

Address of Treating Physician(Required)

Street Address Address Line 2 City State ZIP Code

Was EE Hospitalized as an inpatient overnight?(Required)

Yes

No

Hospital Phone Number(Required)

Address of Hospital EE was Treated at?(Required)

Street Address Address Line 2 City State ZIP Code

Report Completed By?(Required)

First Last

Title of Employer Representative Completing Form?(Required)

Signature of Employer Representative Completing this Form?(Required)

Name

This field is for validation purposes and should be left unchanged.

5020 Employer’s Report of Occupational Injury or Illness