N-0210 Employer_s Report of Occupational Injury Form.pdf

Kern County Sheriff’s Office Policies And Procedures TITLE: EMPLOYER’S REPORT OF OCCUPATIONAL INJURY FORM NO: N-210 APPROVED: Donny Youngblood, Sheriff-Coroner EFFECTIVE: September 15, 1993 REVIEWED: 06/01/2007 REVISED: 03/01/2007 UPDATED: 03/07/2008 N-210-1 POLICY The EMPLOYER’S REPORT OF OCCUPATIONAL INJURY OR ILLNESS form is used to report an occupational injury or illness to the State of California via Risk Management. Attached is a copy of an EMPLOYER’S REPORT OF OCCUPATIONAL INJURY OR ILLNESS form (Form 5020 (Rev7) June 2002) (Attached Exhibit A). The following guidelines will be used to complete the form: LINE # 1. Should read “County of Kern”. 1a. Leave this space blank. 2. Should read “1115 Truxtun Avenue, Bakersfield, CA 93301”. 2a. Should read County of Kern Workers’ Compensation Services phone number (661) 868-3801. 3. List the name and address of the Sheriff’s Office facility or station where the injured