Chapter 7. Division of Labor Statistics and Research
Subchapter 2. Reports of Injury to Be Filed by the California Department of Corrections

Article 2. Reports to Be Filed by Department of Corrections

§14901. Department of Corrections' Report of Injury (Form 5030).

The report shall be submitted in duplicate (Form 5030), to the Division of Labor Statistics and Research on a standard form (Form 5030) approved by the Department of Corrections and the Division of Labor Statistics and Research, Department of Industrial Relations. The following information shall be included on the standard form:

Name, address and phone number of correctional institution;

Name, inmate number, sex, and date of birth of injured inmate;

Date of incarceration;

Type of labor (work) when injured and extent of total experience at that type of labor, and extent of prison training and safety training in that type of labor;

Extent of supervision over work methods used;

Where did the injury occur;

What was the object or substance that directly injured inmate;

Nature of injury and part of body affected;

What was the primary correctable cause of this accident;

What arrangements could be made to eliminate hazard;

Name of physician;

Date of injury;

Was injured unable to work on any day after injury;

Actual or estimated date of injured's recovery;

Date of death if injured died.