CFR > Title 20 - Employees' Benefits > CHAPTER VI—OFFICE OF WORKERS' COMPENSATION PROGRAMS, DEPARTMENT OF LABOR > SUBCHAPTER A—LONGSHOREMEN'S AND HARBOR WORKERS' COMPENSATION ACT AND RELATED STATUTES (parts 701 to 704) > PART 702—ADMINISTRATION AND PROCEDURE > SUBPART B—Claims Procedures (§702.201 to §702.286) > 702.202—Employer's report; form and contents.

702.202—Employer's report; form and contents.

The employer's report of an employee's injury or death shall be in writing and on a form prescribed by the Director for this purpose, and shall contain:
(a) The name, address and business of the employer;
(b) The name, address, occupation and Social Security Number (SSN) of the employee;
(c) The cause, nature, and other relevant circumstances of the injury or death;
(d) The year, month, day, and hour when, and the particular locality where, the injury or death occurred;
(e) Such other information as the Director may require.
(Approved by the Office of Management and Budget under control numbers 1215-0031 and 1215-0063)

Code of Federal Regulations

[58 FR 68032, Dec. 23, 1993]