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Chapter 7. Division of Labor Statistics and Research
Subchapter 1. Occupational Injury or Illness Reports and Records

Article 1. Reporting of Occupational Injury or Illness

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§14005. Reproduction of the Employer's Report. Form 5020 (acrobat version 821 km)

(a) Insurers and self-insured employers shall reproduce Form 5020, Rev. 7, Employer's Report of Occupational Injury or Illness. In reproducing the form, all of the following conditions shall be met:

(1) The title of the reproduced form shall read: State of California Employer's Report of Occupational Injury or Illness. The size of type may be reduced to meet space requirements, but the words “Employer's Report of Occupational Injury or Illness” shall be in bold face type.

(2) The form shall prominently contain filing instructions and the following statements:

(A) “Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony.”

(B) “ATTENTION: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes.” Reference: Section 14300.29(b)(6)-(10)

(C) Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2.

(D) Confidential information may be disclosed to the employee, former employee, or their personal representative (8 CCR 14300.35), to others for the purpose of processing a workers' compensation or other insurance claim; and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (8 CCR 14300.30). 8 CCR 14300.40 requires provision upon request to certain state and federal workplace safety agencies.

(3) The notice block, coding column in the right hand margin, subheadings, spacing, numbering, arrangement, sequence and text of Questions 1 through 39 shall not be altered. However, self-insured employers may eliminate Questions 1A, 2A, 3A, and 37b from reproduced forms and utilize the space to collect other information.

Except as otherwise specified in this Section, any other modification to the content or layout of Form 5020, Rev. 7 may be made only with prior approval of a written request to:

DEPARTMENT OF INDUSTRIAL RELATIONS
CHIEF, DIVISION OF LABOR STATISTICS AND RESEARCH
P. O. BOX 420603
SAN FRANCISCO, CA 94142-0603

(4) Reproduced forms shall be printed on 8 1/2, by 11, paper stock.

(b) Insurers, self-insured employers or other persons reproducing Form 5020, Rev. 7 may rearrange the header block to permit imprinting the following:

(1) Name and address of the insurer, self-insured employer or claims administrator;

(2) Instructions for completing and filing the form;

(3) Coding lines or boxes for special use by the insurer, self-insured employer or claims administrator.

(c) The size of the header block may be altered to gain space for additional questions, which may be included at the bottom of the form, following Question 39, provided the proposed form has been reviewed and approved by the Division. The reverse of the form may be used for additional information or questions.

NOTE

Authority cited: Sections 6410 and 6410.5, Labor Code. Reference: Sections 5401.7, 6409.1(a) and 6410, Labor Code.

HISTORY

1. New section filed 2-8-80; designated effective 5-1-80 (Register 80, No. 6).

2. Amendment of subsections (a) and (c) filed 1-13-83; effective thirtieth day thereafter (Register 83, No. 3).

3. Amendment filed 3-18-87; effective thirtieth day thereafter (Register 87, No. 12).

4. Amendment of subsection (a) filed 6-14-89; operative 7-14-89 (Register 89, No. 25).

5. Amendment of section and Note filed 1-14-93; operative 2-16-93 (Register 93, No. 3).

6. Amendment filed 9-19-2002; operative 10-19-2002 (Register 2002, No. 38).

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