[Code of Federal Regulations]
[Title 20, Volume 3]
[Revised as of April 1, 2003]
From the U.S. Government Printing Office via GPO Access
[CITE: 20CFR702.202]

[Page 875]
 
                      TITLE 20--EMPLOYEES' BENEFITS
 
  CHAPTER VI--EMPLOYMENT STANDARDS ADMINISTRATION, DEPARTMENT OF LABOR
 
PART 702--ADMINISTRATION AND PROCEDURE--Table of Contents
 
                      Subpart B--Claims Procedures
 
Sec. 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)

[58 FR 68032, Dec. 23, 1993]