The employer's report of an employee's injury or death shall be in
writing and on a form prescribed by the Director for this purpose, and
shall contain:
(a) The name, address and business of the employer;
(b) The name, address, occupation and Social Security Number (SSN)
of the employee;
(c) The cause, nature, and other relevant circumstances of the
injury or death;
(d) The year, month, day, and hour when, and the particular locality
where, the injury or death occurred;
(e) Such other information as the Director may require.
(Approved by the Office of Management and Budget under control numbers
1215-0031 and 1215-0063)
[58 FR 68032, Dec. 23, 1993]
