Document O18oGaMerLg8zyxR4XNqE8j7j

ijafe-tti'1 Mila Stall i,B*fnra:liatB.j;, STANDARD FORM EMPLOYER'S FIRST REPORT OF INJURY OR ILLNESS A. Send ORIGINAL to INDUSTRIAL ACCIDENT BOARD, P. 0. Bos 12757, Austin, Tens, 78711 it em ployes is absent from work mors than one day. B. Upon termination of incapacity to employee or H incapacity extends beyond sixty day period, make supplemental report C. Penalty of $1,000 may be assessed for failure to comply with these instruc tions (Sec. 7, Article 8307, VAT.S. amended August 27, 1979). SEND ONE COPY TO LUMBERMENS MUTUAL CASUALTY COMPANY 30 AMERICAN MOTORISTS INSURANCE COMPANY AMERICAN MANUFACTURERS MUTUAL INSURANCE CO. FEDERAL KEMPER INSURANCE COMPANY PO. BOX 40009. MEDICAL CENTER STATION, SAN ANTONIO. TX 78229 State's Number For: MtUAUTED r*-- Board Number...................................................... File:................................................................... Carrier:.................................................................. !.......... Employer:.......................................................... OSHA File No. - Carrier's File No....... (The spaces above art not to be completed by the Employer) i 1. Name of Employer...... E.. I,, dll Pont de . Nemours & Co,............................................................... ......... Telephone .(.512)...572-1JJL 5 2. Office address: No. and St. P . ...Q . ..BOX 2626...........City or Town Victoria.,.............State .....TX......7.79.0.2......... -- 3 Insured hr D LUMBERMENS MUTUAL CASUALTY COMPANY *' ' 5t AMERICAN MOTORISTS INSURANCE COMPANY 33119"'"Q AMERICAN MANUFACTURERS MUTUAL INSURANCE COMPANY Mitt No FEDERAL KEMPER INSURANCE COMPANY '' 4. Give nature of business (or article manufactured) ...... Petrochemicals.. (a) Location of plant or place where accident occurred. # and Street/............................................................................. i............City . Did accident occur on employer's premises? Yes No. (County .........................................State Department where injured..........................................................,..............._____Department regularly employed in , (b) If injured in a mine, did accident occur on surface, underground, shaft, drift or mill?. (c) Was employee hired, or if a Texas resident, recruited in Texas? Yes No (d) If injury occurred out of Texas, on what date was employee transferred out of State?. Date of injury Potential .expo sure, to, a she s. tos... from.. .7/5.0... to.. .7/7 2........... First day unable to labor . No...l.QSt time ... 19 ......... ................... AM.........................P.M. 8. Was injured paid in full for this" When did you or foreman first know of injury?.........................................................................._..1Q. Namt of foreman . 11. Name of Injured 12. Address: No. and St. Full First Name Middle Initial City or Town ... Social Securil ......... SStattaete. .................... Zip Code. as13 14. ac 15. Telephone No. (a) Age 59 . . (b) Sg* . (a)-Occupation wh^.injured * Telephone No. Friend or Relative........... ..................................................... Speak En*lish 0 Yes N JAalb-.(c) Marital Situs ..Married.........(d) Minor Children........JNo.................... .... *:__ ................................................... ... ........ ,(b) Was this his or her regular occupation?................................................................... (cKUoder wha^jpssification code is employee's payroll reported to insurance carrier? ............................................... w. .r................................. 3 16. (a) How long employed by you ................. .....................(b) Piece or time worker................................................. .. (e) Wages per hour $.......... -- 17. (a) No. hours per day...................... (b) Wages per day $................................(c) No. days worked per week.................. (d) Average weekly earnings $ , (e) If board, lodging, fuel or other advantages were furnished in addition to wages, give estimated market value per day, week or month.............. 18. Was injured employee officer, director, partner, or owner? .......... Employee.......................................................... ........... 19 Machine, tool or thing causing injury Asbestos, if , exposed ................................................ 20. Kind of power (hand, foot, electrics steam, etc.) ...... ........... .... 21. Part of machine on which accident occurred .................... .... ................................... .................................... ... j S 22. (a) Name the safely appliance or regulation provided .............. .......................................................................... (b) Was it in use at time?................................................. -- 23. Was accident caused by injured's failure to use or observe safety appliance or regulation?............................... ............................................................................................ ^ 24. Describe fully how accident occurred, and stata what employe* was doing whon injured . Engineer?:.. Const-.--7/SO,...Engineer:.. Nylonr2/55. S3 Div.Supt.: . S/S-1V55,.. Nylon-10/56.,. Nylon-1/59,.. F. Unit-lQ/59, .."Alathan"-2/6Q."Alathan"-7/60, 3 Nylon-4/65, Nylon-r3/66, ,F..Unit-l/71........ .............................. ...... ........................................ .-^cEnpl.Fel.Supt.: Elrpl.Eel.-7/74....Potentia 1.exposure. to asbestos.from..7/50. to .7/72....................... 25. Names and addresses of witnesses ,. ................................................................... ............................................. ..................................................................... 26. Describe the injury or illness in detail and indicate the part of body affected .e.Tli9T.Tl...^?ymP.bpma tic abnormali ties,.............. _ 5 Pleural changes 27. Probable length ol disability No "* O If so, date and hour not resulting...in. disability,................................. ........................ .............................................. lost time. Continue on same job...........4 28. Has injured returned to work? same pay xq^s . .................... ................................................................... At what wage $ ... DU 009337 g 29. At what occupation? ........................................................................................................ ........................ 5 30. (a) Name and addKafS ol physician (if known) S.eg attached list. .................................................................... _ _(b) Name and address of hosoital (if known) -- UJ 5?_1. Has injured died? No _ --- ........................._..................... ................................................................ _ . , "1 _ If so, give date of death .... .... _____ , ............... o *0 Oate of this report I.A 8 Form i (Rev 5-79) tr vs * t <* ia.'yq Firm Name .................................................................................................. Signed by ............................................................................. Official Title INDUSTRIAL ACCIOENT BOARD REQUIRES COMPLETION OF ALL APPLICABLE ITEMS ON THIS FORM O 00 o OJ to [FATAL Question 30: Max Faykus Walter Herbst James Neumann John Starkey VICTORIA RADIOLOGY ASSOCIATES 2710 Hospital Drive Victoria, TX 77901 Dr. Daniel Jenkins, M.D. BAYLOR COLLEGE OF MEDICINE 6560 Fannin, 1608 Scurlock Tower Houston, TX 77030 DUP 0810343 "SAFETY IS MY RESPONSIBILITY" DU 009338