Document M4X8wnZKVMExX3z80mkRN7ObM
FOREMAN'S ACCIDENT REPORT
Injured employee ^
Date of injury
/,/ /^/ -- 7
Last day worked
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Engaged in what work when injured?______ $
Time i`. 14 o'clock
^/
Name and address of doctor or hospital Description of accident
What unsafe condition or act caused accident?;___________________________
^
What action have you taken to prevent similar accidents?
Recommendations for additional action
Foreman and Dept.
E-162-2-55
Form Furnished by Bicuminoi. (o t
Kualty Corporation
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REVIEW BY SAFETY COMMITTEE OR SUPERINTENDENT \.
Recommendation or orders
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Signed
(over)
Date
CYWI 4-001618
Nl4548.01
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CYWI 4-001619 1S14548.02
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PHONfS / Bishop 2-245! l OLymp,c 6-4600
!. UNKOWSKI, M.D. h . j . l a RSON, m.d ,
WEINZIMMER CLINIC
1211 South Cicero Avenue Chicago, Illinois 60650
22, 1971
Ccvpaaf of ^vth Imrim 167 V. ^okni BM.
Chicago, mioii
mo # 20629$
EXPCSTt
Darid *mo* (Ltbcr)
i*8l2-19tli Stroot, Clooro, Illloola Aft 23, rrlod, tfcraa dapanriant afeildran
ASSOBXDc
Aaarloaa Cy-ananld Co^a&f U520 w. I5tn St. Chicago, HHnola
Hisrar o p AccnHffi'-j
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DISABIUTTi
CONFIDENTIAL
^f o r ma t i o n
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KINDLY REPORT THIS CASE TO Y0.UR INSURANCE CARRIER IMMEDIATELY
CYWI 4-001620
N14548.03
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SUPPLEMENTARY RECORD Of OCCUPATIONAL INJURIES AND ILLNESSES_______________
i. n. A-e
EMPLOYER
_________ A-He r i can Cvanamid Co.. Successor to MacGregor Lead Co
. *,_ i:ois
___________4500 W, 15th St., Chicago, Ml. 60623_____________________
V . * C 4 T'ON, . * : * ?tN f r JCM Nil.
OSHA NO. 101 <A84<O0<0I
*- N 4M&
__________ David Munoz
i. -oue >so*csi
INJURED OR ILL EMPLOYEE
SOCIAL SECURITY MO.
48
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SEX
23 i a
2 - 19th St., Chicago, Illinois a- OCCUPATION -- NCONTTaTpN<8SA0UCLTAIVHITJYOSN'ITWLACS PtarOHMIMI
AT TiMC or INJURY
-.... 1 iL Laborer
S. DEPARTMENT - (IISSLRYTSCWSRBBMR*8LS8AI8BRCBLTStPCM8OPPCOLPOTTHT.S4OBB.SHSCIOTOT.STA4W*ToOTWWIBMMMS*TIUStPMIIILrMOWMUSBAtYBiI
Intermediate* Department MacGregor* Chgo.
THE ACCIDENT OR EXPOSURE TO OCCURATfONAL ILLNCfl
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>1 AA! P1.ACC OP ACClOEN 08 EXPOSURE ON (UP^OTfN'l P 8 EMI SC IT
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l]. WHAT WAS EMPLOY** COIN* WHEN INJURBOT PCClTIC. IMS TC 88riglMI w a s miM w it h rpsis.
Cutting pig lead
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OfSCHISC TULLT CVSMTS 8SSUI.T1H0 IN INJU8T 08 0 CCU* AHOMAA ILLHI 08 MSSTAPCCa IWVBLYCO. AMO HOW TM*T WML SITS PULA B*Tlt>*
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CONFIDENTIAL
INFORMATION
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OCCUPATIONAL INJURY OR OCCUPATIONAL ILLKC1
< 4*~~Q ESC PIS* INJURY 08 IL L N ESS l N PET AuT AMO IHW CiT E PART OP DOPY A PPEC^Q. <. IMS St aSWnTsSTBirr IBSE* PI**ES AT S*PS
AC.NT: 88ACTU8 c 08 8188: ICAO 0l 808188: OKSMATina 8P UPT OAMO. CTC.I
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I*. NAME THE OBJECT OR SUBSTANCE WMI CM Ol RE C T L t INJURED THE EMPLOYEE (l.. TNI MAC8IIC TMM| ml TAMS WIM8; m CMIMKM. 08 8 801 Af 108; 08 in TNI CASE 08 8T8A.N8. NC8MIA8 CTC.. TM TOIM8 HI WAS LIPTIH8. PULAIHS. ITC.)
pig of lead
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iga, HOUR . . C fits. OATt 8TAHT80
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3 to 5day
II- NAME AND AOORESS OP PHYSICIAN
Weinzinmer Clinic, 1211 S, Cicero
18. IP HOIPI T AL) ZCO NAME AND AOORESS OP HOSPITAL
OTHER
Ave, Chicago.
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H/29/7!
17. 018 S18PLOT as oi at
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0. STEPS TAKEN TO P**V*NT A RCCuRRBMCS
C^loyee was reinstructed l the handling of pig land
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tell
OPPICIAL POSITION
Plant Manager
CYWI 4-001621
DATE
11/24/71
N14548.04
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CYWl 4-001623 1S14548.05
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CYWI 4-001628
N14548.1
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CTWt 4-001630
Nl4s48.u
CYWl 4-001631
APPLICATION FOR EMPLOYMENT
DO NOT WRITE IN THIS SPACE
Date. 7 /li/fr/
Dept------
Foreman.
Job TitleRote_____
Print Now* Qa.i/tfa
tort
Mu m2. -
First
____
AdArm^/CO PAjL/SJJLt - A Y* -APt1M - ch/tle*
3>. 1 Ho.
City
tT Initio!
T/h>?*>
Towel___ XGI____ Started__
Phone!
Married Date of Birth *7- /& /V.ij /
Soc. See. No.
Q Single
Q Widowed
--------- . -
Divorced U. S. Citizen?.
Height *>
Weight fCC
Any record of convictions?--^
-Are You Physically Handicapped?_A. -For what offense?
-How?.
Have you friends or relatives in our employ?___________________
-Who?
In an emergency, whom shall we notify?
No m
0 r-fefa >
Addrra
Jfr -tbsctf-fu PfieiM
io w related?.
Grade School. High SchoolOther______
yvV
EDUCATION
.Years Attended--
.Years Attended.
*___________ Years Attended.
-Graduate?. .Graduate?. _____ Graduate?.
.Date Left. .Date Left. .Date Left.
EMPLOYER. Address_____
e. 7^
> I.-*- m
What was your job?.
/e
EXPERIENCE
__________________From fdote^ fr1 >>*<>-* -
.to_______
f < -_____City G, o-L -...f c. 2Ciltate_ V
.Salary.
Why did you leave?.
EMPLOYER.________
-From (date).
.to.
Address______________
.City.
.State.
What was your job?.
.Salary.
Why did you leave?. EMPLOYER________ Address______________ What was your job?.
CONFIDENTIAL INFORMATION
REDACTED
.From (date). City.
_to_ .State.
.Saiary.
Why did you leave?. EMPLOYER_________
.From (date).
.to.
Address______________
.City.
.State.
What was your job?.
.Salary.
Why did you leave?.
Armed Forces Serial No.
.Length of Service.
What kind of work do you do best?.
.Second Best?_______
READ OVER THE DATA YOU HAVE GIVEN AND MAKE CERTAIN ALL THE REQUESTED INFORMATION HAS
BEEN ACCURATELY AND COMPLETELY SUPPLIED.
XT- ^
N14548.12
If additional space is needed, use reverse side.
SOU : C v NO .
INSURANCE COMPANY OF NORTH AMERICA ce^TrP:c4re n o
N AM C AN DAO DRESS Off AGENT OR 9ROKER
LIABILITY ACCIDENT NOTICE - N ON-a u T CmC3 i LE
ACOVERAGE C TA TO 3E
Y9 AGENT
L 1MITS
3.1.
P.0
LIABILITY
MEO Pa y me n t s
ELEVATOR
PROOJCTS
CONTRACTUAL
ACGSEGATF
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1
TLIST FORM OR
ENOORSEMEN NUMBER
__F_O_R__E_A_C_H__C_O_V_E_R_AGE- 1(1 N AME
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American Cvanaaid Co.
ADDRESS
POLICYHOLOER
_ 4500 W^.lSth.Sfc..
Chicago.
IHtnols_________.
1 < 'LOCATION OP INSURED PREMISES
SAME a s a s o v e
Pi ph o n e
LJ HOME
bu s 522-2200
T'PLAN
Ol VISION NO.
097
sane
A(2)
OATS
TIME OF ACCIDENT
E 097 Chlcaoo LOCATION
i > am. 5 Xu PM.
(3)
INJURED PERSON
(4)
_____4500_W. 15th St.. MacGregor Lead Plant
N AME
David Kunoz
AODRESS
4312 19th St.. C'ucaao. Illinois
OCCUPATION
EMPLOY ED BY;
Laborer
American Cyananid Co.
WHAT WAS 1NJUREO DOING WHEN HURT'
cutting oia lead
ANATURE
EXTENT OP INJURY
AGE
23 |i-- <--l HOME
G BUS.
PHONE
F
THE INJURY
1WHERE WAS INJUREU Welnzlnvner Clinic
PROBABLE DISABILITY
MMIPe^ebc t or
HAS INJUREO RESUMED WORK7
IS)
PROPERTY DAMAGE
OWNER LIST DAMAGE
(6) N AME
ADORES*
r-, U HOME
BUS-
PHONE
ESTIMATED COST OP REPAIR
LI HOME Q BUS.
PHONE
WITNESSESi
N AME
ADORES*
CONFIDENTIAL INFORMATION
REDACTED
HOME
ph o n e
BUS.
N AME
ADORES*
i t is IMPORTANT
TO GIVE THE FULL NAME ANO
ADORES* OP EVERY Wl Tn CSS
N AME AO OR C SS
HOME U BUS.
ph o n e
HOME US.
PHON c
ol
NAME ADORE**
HOME
us.
PHONE
CL 2SS0 1I-.7 RTO. IN U
(O V ERI
CYWI 4-001634
N14548.13
se = AR *-C _ L A R t o 08'IN
NAMES ANO AOOESSS OF OI S IN T E R e s T E O WITNESSES "HO KNOM a n y t h in g ABOUT Txr
3:;.P5\C NCLuOiNG OATS. BADGE NO. OR NAME OF OOL'CE AUTHORITY TO WHOM THE ACCIDENT WAS REPQRTgo *
while cutting pig ledd
DESCRIPTION DESCRIPTION OP ACCIOEN T
P
IT IS IMPORTANT THAT ANY ARTICLE. PART. OR APPLIANCE CAUSING THE OCCURRENCE 8E CAREFULLY PRESERVED.
Sk e t c h if a p p r o p r ia t e
CONFIDENTIAL
in f o r ma t io n
Re d a c t e d
DOES ANY OTHER INSURANCE APPLY*
Q YES
Q NO
IF YES. IQENTIFY:
SIGNATURE OF INSURE 0
CYWI 4-001635