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:

1. (a) The name, address and business of the employer;
2. (b) The name, address, occupation and Social Security Number (SSN) of the employee;
3. (c) The cause, nature, and other relevant circumstances of the injury or death;
4. (d) The year, month, day, and hour when, and the particular locality where, the injury or death occurred;

5. (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]