This is the date of the most recent injury that resulted in an employee missing at least one full day of work. For the 1st Half of 2020, this date must be between January 1 and June 30, 2020. For the 2nd Half of 2020, this date must be between July 1 and December 31, 2020. The date does not necessarily have to be during this reporting period, if no injuries occurred. If you have not previously reported an injury on this form please use 01/01/1900.
Please check here if information provided above has been updated on this report.