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					                                                              UNITED                                                ATTACHMENT B


                    EMPLOYEE’S REPORT OF OCCUPATIONAL INJURY/ILLNESS
COMPANY NAME                                                                                                        DATE

ACCIDENT LOCATION                                                                                                   DISCIPLINE

EMPLOYEE NAME                                                                                       ID NO.

HOME ADDRESS (STREET)


CITY/COUNTRY                                                                                      TELEPHONE NO.



AGE                                SEX                    MARITAL STATUS                                          NO. CHILDREN

DATE OF INJURY / ILLNESS :*                         TIME OF INJURY ILLNESS:*                             DAY OF WEEK :

HOW DID THE INCIDENT OCCUR?




HOW COULD THE INJURY / ILLNESS HAVE BEEN PREVENTED?




SIGNATURE                                                                                                           DATE



                                         TO BE COMPLETED BY PHYSICIAN/FIRST AID ATTENDANT
DESCRIPTION OF INJURY / ILLNESS*




TYPE OF TREATMENT              IRST AID        OCTOR    HOSPITAL      NONE

DESCRIPTION OF FIRST AID TREATMENT (IF DOCTOR/HOSPITAL, INCLUDE ALL NAME(S), ADDRESS(ES), AND PHONE NO(S).):




DISABLING INJURY / ILLNESS                                                     DURATION OF DISABILITY:

ANALYSIS CODES
NATURE OF INJURY/ILLNESS*          BODY PART                 CAUSE*                        UNSAFE ACT                    UNSAFE CONDITION


                                                                                           ____________________          ________________________
No. ___________                    No. __________            No. ___________


SIGNATURE:                                                                     DATE:



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                                                                  UNITED                                            ATTACHMENT B


                                                                       CODES LIST



CAUSE OF ACCIDENT                         STRUCK OR INJURY BY                       44.   Chest                     36    Inflammation
                                                                                    45.   Sacrum & Coccyx           37    Allergic Reaction
Burn or Scald-Heat Or Cold Exposure       75.   Struck By Falling/ Flying Object    46.   Pelvis                    38    Carpal Tunnel
                                          76.   Struck By Hand Tool In Use          47.   Spinal Cord (Back)        39    Laceration
01 Chemicals                              77.   Struck By Motor Vehicle             48.   Internal Organs           40    Myocardial Infraction (Heart
02 Contact With Hot Object                78.   Struck By Moving Machine Parts      49.   Heart                            Attack)
03 Burn Due To Temperature                79.   Struck: Object Lifted/Handled                                       41    Coronary Oculus
    Extremes                              80.   Struck: Obj Handled By Others                                       42    Puncture
04 Burn Due To Fire Or Flame              81.   Miscellaneous Struck or Inj. By     LOWER BACK                      43    Muscle Spasm
05 Burn Due To Steam/Hot Fluids                                                                                     45.   Swelling
06 Dusts, Gases, Fumes Or Vapors                                                    50. Multiple Lower              46.   Rupture
07 Burn Due To Welding Operations                                                        Extremities                47.   Severance
08 Radiation Burn                                                                   51. Hip                         48.   Arthritis
09 Miscellaneous Burn Or Scald            MISCELLANEOUS CODES                       52. Thigh                       49.   Sprain
                                                                                    53. Knee                        50.   Artherole Scle.
                                          84.   Contact With Electric Current       54. Lower Leg                   51.   Cardiovascular
                                          85.   Animal Or Insect                    55. Ankle                       52.   Strain
                                          86.   Explosion Or Flare Back             56. Foot                        54.   Asphyxiation
                                          87.   Foreign Body In Eye                 57. Toe(s)                      55.   Vascular
CAUGHT IN OR BETWEEN                      89.   Robbery Or Criminal Assault                                         58.   Vision Loss
                                          98.   Cumulative (All Others)                                             59.   All Other
10. Caught in Machine/Machinery           99.   Other                               INTERNAL ORGANS
12. Caught In/Bet Object Handled
13. Miscellaneous                                                                   70.   Liver
                                                                                    71.   Respiratory System
CUT, PUNCTURE, SCRAPE INJURED             BODY PART                                 72.   Circulatory System
BY                                                                                  73.   Nervous System
                                          HEAD                                      74.   Reproductive System
15.   Cut Or Injured By Broken Glass                                                75.   Muscular System
16.   Hand Tool Injury (Non Powered)      10.   Multiple Head Injury                76.   Skeletal System
18.   Powered Hand Tool, Appliance        11.   Skull                               77.   Digestive System          OCCUPATIONAL DISEASE OR
19.   Misc. Cut/Punctures/Scrape/Injury   12.   Brain                               78.   Immune System             CUMULATIVE INJURY
                                          13.   Ear(s)                              79.   Psyche System             60. Dust Disease Noc (All Other)
                                          14.   Eye(s)                              84.   Urinary Tract             61. Asbestosis
FALL OR SLIP INJURY                       15.   Nose                                85.   Lymph System              62. Black Lung
                                          16.   Teeth                               86.   Blood                     63. Byssinosis
25.   Fall/Slip From Different Level      17.   Mouth                               87.   Genitals                  64. Silicosis
26.   Fall/Slip From Ladder/Scaffold      18.   Other Facial Soft Tissue            88.   Rectum                    65. Respiratory Disorder (Gases,
27.   Slip From Liquid/Grease, Spill      19.   Facial Bones                                                              Fumes, Chemicals, Etc.)
29.   Slip Or Fall From Same Level                                                                                  66. Poisoning: Chemicals
30.   Slipped - Did Not Fall              NECK                                      MULTIPLE BODY PARTS             67. Poisoning: Metal
31.   Miscellaneous Slip Or Fall                                                                                    68. Dermatitis
                                          20.   Multiple Neck Injury                90. Multiple Body Parts         69. Mental Disorder
MOTOR VEHICLE                             21.   Cervical Vertebrae                                                  70. Radiation
                                          22.   Cervical Disc                                                       71. All Other Occupational Diseases
45.   Collision With Another Vehicle      23.   Cervical Spinal Cord                MISCELLANEOUS CODES             72. Loss Of Hearing
46.   Collision With A Fixed Object       24.   Larynx                                                              73. Contagious Disease
47.   Crash Of Airplane                   25.   Neck Soft Tissue                    91. Broken Glasses              74. Cancer
48.   Vehicle Upset                       26.   Trachea                             94. Shoulder                    76. Coron. Thrombosis
50.   Miscellaneous Motor Vehicle                                                   99. Unknown                     77. Internal Hemorrhage
                                                                                                                    78. Cerebral Hemorrhage
                                                                                                                    79. Brain Damage
STRAIN OR INJURED BY                                                                NATURE OF INJURY                80. All Other Cumulative Injuries

17.   Strain Or Injury By Jumping         UPPER EXTREMITIES                         Specific Injury
53.   Injury By Holding Or Carrying
54.   Strain Or Injury By Lifting         30.   Multiple Upper Extremities          02    Amputation
55.   Injury By Pushing Or Pulling        31.   Shoulder, Clavicle & Scapula        03    Angina Pectoris
56.   Strain Or Injury By Reaching        32.   Elbow                               04    Bum
57.   Injury By Using Tool/Machine        33.   Lower Arm                           07.   Concussion
                                                                                                                    MISCELLANEOUS CODES
58.   Miscellaneous Strain Or Injury      34.   Wrist                               10.   Contusion
                                          35.   Hand                                18.   Crushing
                                          36.   Finger(s)                           19.   Dislocation               81.   Death
STRIKING AGAINST OR STEPPING              37.   Thumb                               19.   Electric Shock            82.   Quadriplegic
ON                                                                                  22.   Enucleation (Removal Of   83.   Paraplegic
                                                                                            Eye)                    84.   Conjunctivitis
65.   Strike/Step On Moving Parts                                                                                   85.   Ligament
                                                                                    25.   Foreign Body
66.   Strike/Step On Object Lifted        TRUNK                                                                     99.   Unknown
                                                                                    28.   Fracture
67.   Scraping/Cleaning Operation
                                                                                    30.   Freezing
68.   Strike/Step On Stationary Obj.
                                          40.   Multiple Trunk                      31.   Hearing Loss (Temporary
69.   Strike/Step On Sharp Object
                                          41.   Upper Back Area: Thoracic Area              Only)
70.   Misc. Striking Against/Step On
                                          42.   Lower Back Area: Lumber/Sacral      32.    Heat Prostration
                                          43.   Disc                                34.    Hernia
                                                                                    35.   Infection




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posted:4/29/2011
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