Document jyoXeDjg34jwjDYa0nOXneqDk

to* JQMJ S0/td xiywdt rspr m 4 Ms* fart** OifW Wo--ttwii* 4 hmirii Ciil*> M*4l*bvrr. CfaM. MN9 REPORT OF OCCUPATIONAL INJURY OR ILLNESS TO AN EMPLOYEE CASE OR FILE MO _90-13 Company___ Uniroyal Chemical Company, Inc. Plant er Branch _ Painesvilla, Ohio Gty or Town Painesville Slot* Ohio INJURED OR ILL PERSON NAME__Social Sec. ---------------------------------------------------------------------------- -------- -- - Age58 yrs. 10 mo; Address ~- - - City -- -- ,, Slot* -- - ( X) Mai* ( } Femol* - (X ) Married ( ) Single ( jj) Wag* ( J Salary Job Classification -J:-^P -Insgruinenl= Repair^, MaintenanceGenerol OuH*t lns_triiTOent repa Hew long employed prior to injury? - 41 yrs . How long engaged on this job - N/A Whet doing et time of injury? N/A _ ----- -- Had h don* similar work prior to this employment? -- - N/A Hours on job at timo of injury? N/A ACCIDENT OR EXPOSURE Cummulative effects Dato______ __________________ 19_______ HourM Plow pvc Plant (if in building, stale number) Was place of accident or exposure on employer** promises? (X) Yas ( ) No tf no, pleas* explain----- ----------------------- Describe in detail the nature of the injury or illness and the part of the body effected: Hemangiosarcoma of liver Attending Physician: Wgber A. Schulak, M.D.____ HospHoi Norn* & AIWUniversity Hospitals DWI employe# die? { X) Yes ( ) No v-- n** -I fw.eh 11 /1 ?^ irt8 How did the accident er illness occur? (State object and substances involved) - Vinyl chloride - occupational illness. - -- - STATE PRIMARY CAUSE OF ACCIDENT Y?^?Pg81irc t0 vlnyl chlorlde What steps hove been token to prevent the recurrence ef this type of accident?: No longer produce vinyl chloride: plant permanently shut doyn 1975. Dote Lost Time Began -- 10/15/90 Dot* of Return to Work(X ) Check if not returned Answer if employe* has returned to regularly assigned work. (X ) Ooys octvolly disabled from work _____20______ (Lost Workdays) ( ) No. of days assigned to restricted work activity ( ) Nenfotal case without workdays lost ( ) Termination or permanent transfer Oote ef report 2/27/91 Prepared by Official position Industrial Relations Manager -- (Restricted Workdays) , * ' -- UNIR0000830