DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
POLICY AND PROCEDURES MANUAL
NOTICE OF ACCIDENT-RELATED VIOLATION
Issue Date: 5/15/94
AUTHORITY: California Labor Code §6319(d).
POLICY: It is the policy of the Division of Occupational Safety and Health to prepare a Notice for the employer, following each investigation of an industrial accident or occupational illness, if a fatal or serious injury, illness or exposure was related to a serious, willful or repeat violation or the employer's failure to correct a previously cited serious violation within the time fixed for abatement.
A. FIELD PROCEDURES
After a thorough investigation of each industrial accident or occupational illness, compliance personnel shall determine whether a serious, willful or repeat violation, or the employer's failure to correct a previously cited serious violation within the time fixed for abatement, noted during the course of the investigation, is related to any fatal or serious injury, illness or exposure at the investigated workplace.
Compliance personnel shall prepare a Notice of Accident-Related Violation After Investigation for issuance from the District Office when violations referenced in subsection A.1. are noted during the investigation of an industrial accident or occupational illness which are related to the accident or illness.
Upon request, compliance personnel shall provide the employer with a copy of the inspection report at a nominal copying cost.
B. OFFICE PROCEDURES
C. FORM COMPLETION
Enter the name, address and telephone number of the issuing District Office.
Enter name and mailing address of the employer.
Enter page number in the first space provided and in the next space provided, enter total number of pages.
Enter the location of the inspection site, the name of the inspecting compliance personnel and the date of the inspection.
NOTE: If the inspection required more than one day, indicate the inclusive dates.
For each injury or illness, enter in easily understand able language a description of the circumstances or condition which caused the industrial accident or occu pational illness. Note the exact location of the accident, referencing the site, building, and/or plant. In addition, indicate the classification and Title 8 Safety Order section of each violation related to the condition(s) described in Item 5.
Compliance personnel shall sign his or her name legibly.
District Manager shall sign his or her name legibly.
Enter the date that the Notice (Cal/OSHA Form 170C) was mailed or delivered to the employer.
Enter the date that the inspection was completed.
Enter the Region, District, SE/IH ID Number, Optional Report Number and the Cal/OSHA Form 1 preprinted Nine- digit Report No. in the spaces provided.
Attachment: Cal/OSHA 170C