AGENCY: Department of Transportation. Employee Safety

SERIES: 6763
TITLE: Employer's report of injury or occupational disease
DATES: i 1985-
ARRANGEMENT: None

DESCRIPTION: This is the agency copy of the report documenting an injury to an employee while on the job and the nature of the accident. The original is filed with the Office of Worker's Compensation and a copy is sent to the Industrial Commission of Utah to claim worker's compensation. This report includes the date, time, and nature of the accident or diagnosis of occupational disease; extent of injury or fatality; information identifying employer and place of employment; names and addresses of witnesses and attending physician; and the following data elements concerning the injured employee: age, current and past addresses, date of birth, employer, job position information (grade/step, etc.), marital status, medical information, name of kin, number of children, occupation, salary, sex, social security number, telephone number, and any past injuries incurred on the job.

RETENTION

Retain for 5 year(s)

DISPOSITION

Destroy.

RETENTION AND DISPOSITION AUTHORIZATION

These records are in Archives' permanent custody.

APPROVED: 10/1986

FORMAT MANAGEMENT

Paper: Retain in Office for 2 years and then transfer to State Records Center. Retain in State Records Center for 3 years and then destroy.

APPRAISAL

Administrative

General Schedule 1, Item 31 lists a retention of 5 years.

PRIMARY DESIGNATION

Private