File ASISTS_ACCIDENT_REPORTING(2260) Data List
| CASE NUMBER |
PERSON INVOLVED |
STATE |
HOME PHONE NUMBER |
GRADE/LEVEL DATE OF INJURY |
STEP AS OF DATE OF INJURY |
EMPLOYEE STREET ADDRESS |
EMPLOYEE CITY ADDRESS |
EMPLOYEE STATE ADDRESS |
EMPLOYEE ZIP CODE |
DEPENDENTS |
PLACE WHERE INJURY OCCURRED |
DATE/TIME INJURY OCCURRED |
ZIP CODE |
DATE OF THIS NOTICE |
OCCUPATION |
CAUSE OF INJURY |
NATURE OF INJURY |
REQUEST PAY OR LEAVE |
NAME OF WITNESS |
WITNESS ADDRESS |
WITNESS CITY |
WITNESS STATE |
WITNESS ZIP CODE |
DATE OF WITNESS SIGNATURE |
STATEMENT OF WITNESS |
NAME OF EMPLOYEE |
EMPLOYEE ELECT. SIGNATURE |
EMPLOYEE DATE OF SIGNATURE |
OCCUPATION CODE |
TYPE CODE |
SOURCE CODE |
WITNESS NAME |
CAUSE OF INJURY CODE |
STATION NUMBER |
AGENCY NAME |
AGENCY ADDRESS |
AGENCY CITY |
AGENCY STATE |
AGENCY ZIP CODE |
OWCP CODE |
OSHA SITE CODE |
REGULAR HRS FROM TIME |
REGULAR HRS TO TIME |
COST CENTER/ORGANIZATION |
REGULAR WORK SCHEDULE |
DATE OF INJURY |
DATE/TIME WORK STOPPED |
DATE PAY STOPPED |
DATE 45 DAY PERIOD BEGAN |
DATE/TIME RETURNED TO WORK |
INJURED PERFORMING DUTY |
NOT INJURED PERFORMING JOB |
INJURY CAUSED BY EMPLOYEE |
CAUSED BY EMPLOYEE EXPLAIN |
INJURY CAUSED BY 3RD PARTY |
3RD PARTY NAME |
3RD PARTY ADDRESS |
3RD PARTY CITY |
3RD PARTY STATE |
3RD PARTY ZIP CODE |
PHYSICIAN NAME |
PHYSICIAN ADDRESS |
PHYSICIAN CITY |
PHYSICIAN STATE |
GRADE |
PHYSICIAN ZIP CODE |
FIRST DATE MEDICAL CARE |
DISABLED FOR WORK |
SUPERVISOR AGREE/DISAGREE |
SUPERVISOR NOT AGREE EXPLAIN |
REASON AGENCY CONTROVERTS COP |
AGENCY CONTROVERT |
AGENCY DISPUTE |
PAY RATE DOLLAR |
PAY RATE PER |
SUPERVISOR EXCEPTIONS |
NAME OF SUPERVISOR |
STEP |
SUPERVISOR ELECT. SIGNATURE |
SUPERVISOR DATE OF SIGNATURE |
SUPERVISOR TITLE |
SUPERVISOR OFFICE PHONE |
SUPERVISOR PHONE EXT |
FILING INSTRUCTIONS |
DATE NOTICE RECEIVED |
EMPLOYEE DUTY STATION |
DUTY STATION ADDRESS |
DUTY STATION CITY |
DUTY STATION STATE |
EDUCATION |
DUTY STATION ZIP CODE |
ZIP CODE WHERE INJURY OCCURRED |
PHYSICIAN TITLE |
INJURY OCCURRED ADDRESS |
INJURY OCCURRED CITY |
INJURY OCCURRED STATE |
HEPATITIS B |
WORKER'S COMP EDIT |
PERSONNEL STATUS |
HEPATITIS C |
GRADE AS OF LAST EXPOSURE |
STEP AS OF DATE OF ILL. |
EMPLOYEE OCCUPATION |
ILLNESS OCCURRED (LOCATION) |
HIV |
ILLNESS OCCURRED ADDRESS |
ILLNESS OCCURRED CITY |
ILLNESS OCCURRED STATE |
ILLNESS OCCURRED ZIP CODE |
DATE FIRST AWARE OF ILLNESS |
DATE FIRST REALIZED CAUSE |
RELATIONSHIP OF ILLNESS TO EMP |
NATURE OF DISEASE/ILLNESS |
CLAIM NOT FILED |
EMPLOYEE STATEMENT DELAYED |
OTHER |
MEDICAL REPORT DELAYED |
DATE OF EMPLOYEE SIGNATURE |
OWCP USE NOI CODE |
DATE ORDERED |
OWCP AGENCY CODE |
DATE DRAWN |
NAME OF PHYSICIAN |
FOLLOW-UP DATE |
DATE/TIME PAY STOPPED |
DATE OF LAST EXPOSURE |
WORK DUTY CHANGED |
GENERAL SETTING OF INCIDENT |
SUPERVISOR EXCEPTION |
SUPERVISOR PHONE |
LOCATION OF INJURY |
DESCRIPTION OF INCIDENT |
CHARACTERIZATION OF INJURY |
MEDICAL EMERGENCY |
TYPE OF INCIDENT |
BODY PART MOST AFFECTED |
ADDITIONAL BODY PART AFFECTED |
VETERAN |
RECEIVE VETERAN BENEFITS |
PENDING DISABILITY CLAIM |
VBA NUMBER |
MILITARY CLAIM BODY PARTS |
CONDITION ACCEPTED IN CLAIM |
EMP NAME OF DUAL BENEFIT |
SIDE OF BODY AFFECTED |
EMP DUAL BENEFITS E-SIGNATURE |
EMP DUAL BENEFIT SIGN DATE |
WC NAME FOR DUAL BENEFIT |
WC DUAL BENEFITS E-SIGNATURE |
WC DUAL BENEFITS SIGN DATE |
DUTY RETURNED TO |
LOST TIME |
OWCP SUFFIX |
OWCP CODE (6 CHARACTER) |
AGENCY CONTROVERTS CODE |
DATE OF DEATH |
ILLNESS TYPE |
TIME WORK BEGAN |
HIRE DATE |
PRIVACY CASE |
NON VA ER TREATMENT RCVD |
HOSPITALIZED AS INPATIENT |
PATIENT SOURCE |
TREATING PHYSICIAN |
TREATED AT DIFFERENT FACILITY |
OTHER FACILITY NAME |
OTHER FACILITY STREET |
OTHER FACILITY CITY |
OTHER FACILITY STATE |
OTHER FACILITY ZIP |
REASON FOR DISPUTE CODE |
LOCATION DETAIL |
LOSS OF CONSCIOUSNESS |
CONTAMINATION |
PRESCRIPTION STRGTH MEDS GIVEN |
NON-SCRIPT MEDS AT SCRIPT DOSE |
INITIAL RETURN TO WORK STATUS |
DUAL REFUSED |
WEATHER FACTOR |
SOURCE OF INCIDENT |
CAUSE OF INCIDENT |
ADDITIONAL CAUSE OF INCIDENT |
PREVENTIVE METHOD |
STATUS OF CORRECTIVE ACTION |
PURPOSE OF SHARP OBJECT |
SEVERITY OF INJURY |
ACTIVITY AT TIME OF INJURY |
OBJECT CAUSING INJURY |
OSHA 300 COLUMN F |
AREA EXPOSED TO BODILY FLUID |
DATE/TIME OF OCCURRENCE |
PERSONAL PROTECTIVE EQUIPMENT |
BODILY FLUID EXPOSURE SOURCE |
EQUIPMENT/DEVICE FAILURE |
EQUIP/DEVICE FAILURE OCCURRED |
SAFETY DESIGN DEVICE USED |
SUPERVISOR |
SUPERVISOR ELECTRONIC SIG |
SUPERVISOR SIGNATURE DATE |
CORRECTIVE ACTION |
SAFETY OFFICER NAME |
SAFETY OFF. ELECT. SIGNATURE |
SSN |
SAFETY OFF. DATE SIGNED |
CASE STATUS |
INJURY/ILLNESS |
SECONDARY SUPERVISOR |
NEEDS XMIT TO NDB |
SAFETY OFF. COMMENTS |
PERSON ENTERING STUB RECORD |
DATE TRANSMITTED TO NDB |
REASON FOR DELETION |
TRANSMITTED TO NDB |
DATE OF BIRTH |
EMP RETIREMENT COVERAGE |
EMP RETIREMENT COVERAGE DESC |
NOI CODE |
PAY PLAN |
DATE TRANSMITTED TO WCMIS |
TRANSMIT TO WCMIS |
WC ELECTRONIC SIGNATURE |
WC DATE OF SIGNATURE |
SEX |
OWCP CHARGEBACK CODE |
EMPLOYEE BILL OF RIGHTS OK |
EMPLOYEE CONSENT |
OWCP DISTRICT OFFICE |
VALIDATION CODE |
VALIDATION VERSION |
NAME OF SAFETY OFFICER |
SAFETY OFFICER ELEC. SIGN |
SAFETY OFF. ELEC. SIGN DATE |
EMPLOYEE HEALTH NAME |
HOME STREET ADDRESS |
EMP HEALTH ELECT. SIGNATURE |
EMP HEALTH ELECT SIGN DATE |
BRAND |
DEVICE SIZE |
SAFETY CHARACTERISTICS |
SAFETY DEVICE NOT USED |
SERVICE |
INJ PRIOR TO SAFE DEV ENGAGED |
INCLUDE ON OSHA LOG |
FATALITY |
CITY |
DATE/TIME STUB CREATED |
INCIDENT OUTCOME |