|DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
POLICY AND PROCEDURES MANUAL
IMIS DATA ENTRY for the Cal/OSHA 36(S)
Issue Date: 2/1/02
An OSHA 36(S) electronic version of the Cal/OSHA 36(S) now exists on the IMIS. At the discretion of the District Manager, compliance personnel may use the electronic OSHA 36(S) in lieu of the pre-printed Cal/OSHA 36(S). The electronic OSHA 36(S) automatically generates the nine-digit pre-printed event number.
MOD/Date -- Not used. If modifications are made, photocopy the original Cal/OSHA 36(S) and circle in red ink all items on the photocopy which are to be modified.
1. Reporting ID
Enter the Reporting ID of the District Office.
2. Previous Activity -- Not used.
3. Event Number
The preprinted 9-digit number on the Cal/OSHA 36(S) is used to uniquely identify this report and must be used when modifying the event data. If more than one cell is received for a single accident event, it shall be regarded by the District as ONE event and only one 9-digit Activity Number shall be assigned.
4. Establishment Name
5. Employer ID -- Not used.
6. Site Address
7. City Code
Enter the 4-digit code for the city in which the worksite is located. If the establishment is not in a city, enter the code for the nearest city within the county in the State of California. City codes are listed in P&P Appendix III. On the micro, the code will prefill.
8. County Code
Enter the 3-digit code for the county in which the work- site is located. If the establishment is not in a county, e.g., offshore drilling, enter the code for the nearest county within the State of California. County codes are listed in P&P Appendix III. On the micro, the code will prefill.
9. Mailing Address
Enter the street or highway address, P. O. Box, City, State, Zip Code of the employer's location where the citations will be mailed if other than the site address.
10. Type of Business
Enter a brief description of the type of activity performed by the establishment in which the event occurred.
11. Primary SIC
Enter the 4-digit Standard Industrial Classification (SIC) Code from the SIC Manual (1987 Edition) to indicate the type of industrial activity performed by the employer at the event site. On the micro, the code may be located through the F2 choice list function.
If it is not possible from the information available to determine the complete 4-digit SIC code, classify the establishment based on the primary activity and code at the 2-digit level.
EXAMPLE: An establishment is known to manufacture tobacco (SIC 21), but it is not known which specific product, cigarettes (SIC 2111) or pipe tobacco (SIC 2131), is produced. In this case, SIC Code "2100" is an acceptable SIC Code entry.
12. Number of Employees
Enter whatever number is known or can be estimated.
Mark "X" in the one box which describes the ownership of the establishment. On the micro, codes are displayed for making a selection.
14. Reported By
Enter the name of the person making the initial report, if available. In addition, if the report is made by an employer representative, indicate this by adding the notation "ER" after the name.
Enter the month, day and year that the report was received.
Enter the time that the event was reported and circle am or p.m.
17. Job Title
Enter the job title of the person whose name appears in Item 14.
18. Telephone Number
Enter the telephone number, including the area code, of the person whose name appears in Item 14.
19. Group Name(s)
If employees involved in the event reported are represented by unions, identify which groups represent them, if known.
20. Name and Location
Enter the name of a person at the event site who can be contacted by Cal/OSHA personnel and the location at which this person can be contacted.
21. Job Title
Enter the job title of the person whose name appears in Item 20.
22. Telephone Number
Enter the telephone number, including area code, of the person whose name appears in Item 20, if known.
Mark "X" in the appropriate box to indicate the classification of the event.
NOTE: If classification changes after the initial report is completed, it need not be modified unless the change results in a change in the action planned.
a. Fatality. Mark "X" in this box whenever an employee death occurs.
b. Catastrophe. Mark "X" in this box if the event meets the definition of a catastrophe--the inpatient hospitalization, regardless of duration, of three or more employees resulting from an employment injury, illness or exposure caused by a workplace hazard or condition.
c. Non-Fatality/Catastrophe Reported By Professional or Media. Mark "X" in this box whenever an event, which is not a fatality or catastrophe, is reported by a safety or health professional, another government agency or the media.
d. Non-Fatality/Catastrophe Reported by Employee, Employer or Other Party. Mark "X" in this box whenever an event, which is not a fatality or catastrophe, is reported by an employee, an employer or some party other than those identified in Item c above.
24. Event Date
Enter the month, day and year that the event occurred.
25. Event Time
Enter the time and circle am or p.m.
26. Number of Fatalities
Enter the reported number of fatalities.
27. Number of Hospitalized Injuries
Enter the reported number of injured employees who were admitted as an inpatient to a hospital or equivalent medical facility for examination or treatment.
NOTE: If, upon investigation, it is determined that the number of employees admitted has changed, compliance personnel or District Office support personnel shall modify this entry.
28. Number of Nonhospitalized Injuries
Enter the reported number of injured employees that were not hospitalized.
29. Number Unaccounted For
Enter the reported number of people unaccounted for in the event.
30. Type of Event
A description of the type of event in a brief, one line narrative (60 character limit), such as "fall from scaffold" or "grain elevator explosion," based on information available from the source.
NOTE: This item must be completed whether or not an inspection is conducted. It will be used in scanning all Cal/OSHA 36(S) to identify cases of interest.
31. Preliminary Description
Describe the event as completely as possible based on the information available from the source and record any significant circumstances.
Enter any information that will assist the District Manager in deciding whether to investigate the accident event. Information that would assist compliance personnel in preparing for an investigation should also be obtained. This would include identification of hazardous materials that would require personal protective equipment or sampling equipment.
This space may also be used for names of injured and/or deceased individuals and witnesses as well as any other information the District Office may need, such as the date of the employee's death(s).
32. Inspection Planned?
Yes, Mark "X" if an inspection is planned.
No, Mark an "X" if no inspection is planned.
If No, Reason: If no inspection is planned, justify the decision why no inspection is planned.
33. Supervisor(s) Assigned
For District Office optional use.
34. CSE/IH ID (Compliance Personnel) Assigned
Enter the name of the compliance personnel ID assigned to investigate the accident event.
35. Optional Information
NOTE: The paper form of the Cal/OSHA 36(S) does not have a preprinted area designated for Strategic Performance Goals. Therefore, compliance personnel shall write in Item 35, the appropriate Strategic Performance Goal that the accident event corresponds to. The ID Field is to be left blank. For IMIS Data Entry, the goal is not entered in Item 35, rather it is a recognizable area to remind the data enterer to input the Performance Goal in Line 38 of the Accident Data Entry Screen. Line 38 of the Accident Data Entry Screen has a pop-up window where the specific Performance Goal is selected from the Choice List provided.
|SP||ASHIP||Agricultural Safety and Health Inspection Project||0111 through 0783|
|SP||CSHIP||Construction Safety and Health Inspection Project||1521 through 1799|
|SP||RMI||Repetitive Motion Injuries||All SIC Codes|
|SP||TARGET||Targeted Inspection Program||2046, 2051, 2421, 2434, 249, 251, 4491, 805 and all other SIC Codes designated by the High Hazard Unit|