Supplemental Record of Occupational Injuries and Illnesses ( OSHA Form 101 )

Case#:

OM000001

RECNO:

1

Employer

1. Name:

TBDL

2. Mail Address:

tbd

AB

12345-6789

3. Location:

tbd

Injured or Ill Employee

4. Name:

Rich

Strong

SSAN

800-COSMIC0

5. Home Address:

123 Main

Anytown

AA

01234-5678

6. Age

67

7. Sex

( Yes=>"1", No=>"0")

Male

1

Female

0

8. Occupation:

burning

9. Department:

Safety Analysis Sys

The Accident or Exposure to Occupational Illness

10. Place of Accident or Exposure:

WrkRecId J0000002, TxtFil HK000001

11. Was place of accident or exposure on employer's premises?

Yes

tbd

No

n/a

12. What was the employee doing when injured?

13. How did the accident occur?

Input OSHA directives.

Worker failed to ensure clear path. Other worker failed to cleanup

spill

Occupational Injury or Occupational Illness

14. Describe the injury or illness in detail and indicate the part of body affected.

Part:

Fall off roof

foot

15. Name the object or substance which directly injured the employee.

USA

HazMat A

16. Date of injury or initial diagnosis of occupational illness.

12/27/1995

asphyx.

17. Did employee die?

Yes

2

No

1

Other

18. Name and Address of Physician:

19. If hospitalized, name and address of hospital:

SIC/NAIC 9999 Rate=nn.n / khrs

Date:

02/02/1997

Prepared By:

Dick

Strong

Position:

937-236-2113

TEXTFILE:

LAPSRECNR:

1

FONE:

800-COSMIC-

0

Lost Days:

3

Ending:

12/31/1995

Restricted Days:

14

Ending:

12/04/1994