Document bBb5Zm46q86Q4zqRQvp95Yppy

;y / i > /'i < :i STATE OF ILLINOIS . it FOR STATE OF ILLINOIS USE ONL'i DATE RECEIVED INDUSTRIAL COMMISSION 160 N. LA SALLE ST., CHICAGO, ILLINOIS 6Q601 EMPLOYER'S FIRST REPORT OF INJURY OR ILLNESS (COPY SHOULD BE SENT TO INSURANCE CARRIER IMMEDIATELY) - * U C EMPLOYER NO. FILE NO. (OSH AI ALL EMPLOYERS ARE REQUIRED TO SUBMIT THIS REPORT TO. THE ILLINOIS INDUSTRIAL COMMISSION UNDER ILL. PUB. ACTS 77*1900, 77-1901 and 77-1902 DATE OF REPORT 7/23/73 ILL. UNEMPLOYMENT COMPENSATION NO. SIC CODE REPORT DATE SIC EMPLOYER S NAME American Cyanamid Company DOING BUSINESS UNDER THE NAME OF MacGregor Lead Plant E M MAILING ADDRESS 4500 W. NO. 15th St, P CITY STATE L Chi cago, 111 STREET ZIP CODE 60623 0 PLANT LOCATION IF DIFFERENT THAN MAILING ADDRESS Y STREET CITY COUNTY Cook ZIP CODE ZIP 60623 COUNTY Ef EMPLOYER'S PHONE NO. R `aR^c o o e'3 i 2-522-2200 IS EMPLOYER: INDIVIDUAL PARTNERSHIP ac IF MORE THAN ONE PLANT, PHONE EMPLOYER NO. OR ' _ ( )- NATURE OF BUSINESS OR SERVICE (MFG, TRANSPORT, ETC) SPECIFIC PRODUCT OR SERVICE INS. CO. NO. lead stabilizer manufacturer 1ead stabi1izers NAME OF WORKMEN'S COMP. INS. CO. OR, IF SELF-INSURED SPECIFIC OR AGGREGATE CARRIERS . MA 1 NA NUMBER OF EMPLOYEES^ Q (1) TOTAL NO. LAST REPORTED FOR UNEMPLOYMENT COMPENSATION PURPOSES -30,, NAME LAST FIRST MIDDLE Moore MAILING ADDRESS Leroy STREET CITY 4101 S. Federal, Chicago, 111 POLICY NO. SELFINSURED POLICY NO. ED 0 SELF (Z) IF MORE THAN ONE PLANT, NO. AT LOCATION WHERE INJURY OR ILLNESS OCCURRED NO. EMPL. NO. EMPL, SOCIAL SECURITY NO. 347=46-4145 STATE SEX ns SINGLE 0 >< st at u s Oma r r ie o I IQIVORCED ZIP CODE SOC. SEC. NO. SE* s t at u s 60609 E DATE OF BIRTH M 7/24/53 AGE 19 P JOB TITLE OR OCCUPATION L general factory IS EMPLOYEE pEATO," >StS NAME OF DEPT. NORMALLY LENGTH OF ASSIGNED , _ TIME WITH general factory FIRM 7 mo WAS EMPLOYEE TEMPORARILY WORKING IN ANOTHER DEPT. OR JOB AT TIME OF INJURY OR r ILLNESS? X> HOW LONG HAS EMPLOYEE WORKED AT JOB AT WHICH INJURY - OR ILLNESS OCCURRED? / ITIOS . BIRTH DATE AGE OCC. CODE TEMP MINOR TIME O AVERAGE WEEKLY EARNINGS Y '$ NUMBER OF CHILDREN UNDER 18 AT TIME OF INJURY OR ILLNESS DID EMPLOYEE DIE AS A RESULT EARNINGS CHILDREN DIED OF INJURY OR ILLNESggg Qjjg E IF EMPLOYEE (l)DATE OF DEATH (2) GIVE NAME, ADDRESS, AGE AND RELATIONSHIP OF DEPENDENTS DATE OF DEATH E DIED: 19 20 Ip 21 J U R 22 Y DATE OF INJURY OR OF DIAGNOSIS ILLNESS E ~ - ' : 3tTIWHAT SHIFT WAS EMPLOYEE WORKING1 t ime WAS INJURY OR EXPOSURE I p m I I OPRNEEEMMISPELSO?YY6ERR'S PLACE OF JNJURY OR. EXPOSURE : ESTABLISHMENT NO. REPORT OF STREET !' Vl MacGregor Lead'Plant 4500 W. 1 St. ' "i CITY; STATE ZIP CODE COUNTY Chicago, 111. J\ 60623 WHAT WAS EMPLOYEE DD'dilNG,'WHEN INJURY/ ILLNESS OCCURRED? /,: ,' WHAT MACHINE OR TOOL? Coolc .< WHAT OPERATION? turning electric hand truck around 'v 23 Y; , PJ I ;24 l: l HOW DID INJURY / ILLNESS OCCUR? TELL ALL OBJECTS AND.SUBSTANCES INVOLVED. IN INJURY / ILLNESS `truck Tan ove r* hi S foot '? T 25 e ' >G INJURYDATE TIME PREM IN OH ILL REPORT LAG COUNTY ZIP CAUSE OR SOURCE-, ACCIDENT TYPE Ja r t o V'b o d v a f f e c t e d " left Instep mi) INJURY / ILLNESS OUClift UUHINU ANY Pimm PHYSltAl IFSO, WIIA1 f [AHT jCTFUj an d in t h e c o u r s e o f EMPLOYMENT? [yj]<OD"ttEECUtSa?'Bfflconqenltal defo ml ty NATURE AND EXTENT OF INJURY / ILLNESS (BE SPECIFIC* k in d NATURE 29 i . N contusion, dorsum-of left foot J 30 U R Y LAST DAY WORKED h 7/18/73 DATE RETURNED TO WORK 7/19/73__________ IF DID NOT RETURN, DATE EXPECTED BACK LAST DAY RETURNEC no lost time I DID INJURY / ILLNESS 32 OCCUR BECAUSE OF UNSAFE FAILURE TO FAILURE TO x(aemxx>xmm OBEY RULES LAST DAY TO OCCURRED OMXXXKXX emx RETURN LAG IF EMPLOYEE TREATED, WHO? WHERE? NO. STREET CITY STATE ZIP CODE CASE CODE STATUS 33 Clearing Clinic, 55^8 W. 65th St, Chicago, 111. 60638 IF HOSPITALIZED, HOSPITAL NAME, ADDRESS NO. 134 STREET CITY STATE ZIP.CODE NUMBER LOST DAYS 35 C- No N IS COMPENSATION BEING PAID? RATE OF COMPENSATION $ /WEEK DATE FIRST PAYMENT TO WHOM? 36 MA PT EA ARE MEDICAL AND/OR HOSPITAL BY WHOM? SERVICES BEING r^ri r^-l N L FURNISHED? I VESI Lij-U S = HAS COMPENSATION r^i c e337 A F BEEN PAID? TO WHOM? RELATIONSHIP RATE OF COMPENSATION S /WEEK :t LENGTH OF DISABILITY BEFORE DEATH (DAYS) HAVE FUNERAL AND BURIAL 38 EXPENSES BEEN I-------- 1 I-------- 1 PAID?_____________ YES NO BY WHOM? DATE FIRSTPAYMENT REPORT 39 PREPARED BY: NAME R. K. Felter SIGNATURE TITLE DATE Plant Manager 7/23/73 RATE $____ SERVICES DATE COMP PATE $ LENGTH DATE BURIAL A FILING OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY-ONLY A REPORT OF THE ALLEGED ACCIDENT OR OCCUPATIONAL DISEASE NOTE: Every employer subject to the Illinois Workmen's Compensation and Occupational Diseases Acts shall file with the Illinois Industrie Commission a report, in writing, of all occupational injuries, illnesses and diseases arising out of, and in tho course of th< employment and resulting in death, disablement, or illness resulting in the loss of more than one scheduled work day or the inability of an employee to continue in his regular job. In case of death such report shall be made no later than 2 working days following the occupational death. In all other cases such report shall be made between the 15th and 25th of each'month unless required to be made sooner by rule of the Illinois Industrial Commission. Failure to file with the Illinois Industrial Commission any of the report; required by law is a misdemeanor punishable by a fine of not less than $100 nor greater than $200. All reports filed hereinunder shall be confidential and any person having access to such records filed with the Illinois Industrial Commission as herein required, who shall release .any information therein contained including the names or otherwise identify any persons sustaining injuries or disabilities, or give access to such information to any unauthorized person, shall be subject to discipline or discharge, and in addition shall, upon conviction, be punished by a fine of not more than $1,000 or by imprisonment for not more than 6 months, or both. NOTE Any changes in status of case, including the commencement or stoppage of compensation payment, must be reported on CAREFULLY: Employer's Supplementary or Final Report of Injury or I Illness (Form I.C. 85). CY 0005358