k. Any evidence of contributory cause other than accident?_ 1. If so, a. If you did not give first treatment, give date of first attendance b. Called by employer or employé ?__ C. Where was employé treated?__ procedure, etc. d. Treatment, surgical e. Will employé be able to resume regular occupation?__ f. If so, approximately when?_____. Date of report_. Street No.-. Made out by Dr... City or town__. PART II. This Part to be filled in and sent with Part I if the injured employé has then died, or been discharged, or the physician's attendance terminated from other cause. Otherwise detach Part II after writing in names for identification, and fill in and send to Board after last attendance. Name of employer___. Name of injured employé‒‒‒‒‒‒ 1. Treatment. a. Note operations and other material facts subsequent to those stated in Part I_____. b. Was patient confined to hospital?__‒‒‒‒ d. How long?_ f. How long?-- do any work?_ e. Professional nurse needed?_ c. Or home?. g. Was patient during treatment able to h. What work and how much of the time?__ a. b. 2. Result. c. Did it cause any permanent Did injury result in death?.. injury?------ d. If so, state its nature exactly_. If unable to do regular work, able to do any other?- j. When? Date of report--- Made out by Dr.----. § 282. Form of request for report of accident. (1) The Industrial Accident Board is informed that an accident happened to-----------on or about___‒‒‒ at in the course of his employment by you. If said employé was kept from work for a period of less than one week, simply so advise. If he lost one week or more, please make full report and state reasons for delay. Kindly answer all pertinent questions on the blanks enclosed. If the employé has recovered, make both First and Supplemental Reports now. If he is still disabled, make First Report now, and Supplemental Report in conformity with the instructions printed on that form. Very truly yours, Statistician. § 283. Form of request for fuller report of accident. (m) The Industrial Accident Board acknowledges, with thanks, the receipt of your report of the accident to‒‒‒‒‒‒‒ Fuller information being required, you are requested to fill in the enclosed form and to return it promptly. It is also called to your attention that reports are required of all industrial accidents, excepting only those causing disability of less than seven days, which have happened since January 1st of this year. If you have omitted to report any such accident, please report at once. Additional report forms have been mailed to you under separate cover. If more are needed they will be sent on request. By... Yours very truly, INDUSTRIAL ACCIDENT BOARD, § 284. Form of notice to doctor to file report (n). Dear Doctor: 11110 It is reported that you attended-----injured in an accident on or about---1912. Enclosed please find a copy of the statute relative to reporting industrial accidents, and a blank which we request you kindly to fill in and return. No report is required if the injured person was incapacitated for less than one week. In that contingency, or if the report of your connection with the case is in error, may we request that you kindly so advise? Your prompt attention will oblige, Sincerely yours, INDUSTRIAL ACCIDENT BOARD, By... GROUP V. § 285. Forms to be used by casualty companies.The forms required to be used by casualty companies as prescribed by the Industrial Accident Board of California are designated and entitled as follows: (0) First accident report of casualty company; (p) Supplemental accident report of casualty company, and are set forth in the order named in the sections that immediately follow: § 286. Form of first accident report of casualty company. (o) (Give name of Company.) Report only accidents causing disability of one week or more. (11) Full description of accident, and cause thereof. Injury. (12) Was accident fatal________ (13) If fatal, date of death---- (14) Nature of injury.. (15) Probable period of disability. (Report in days.) Additional Data. § 287. Form of supplemental accident report of casualty company. (p) (7) Date of first report by Company to Board.. Claim for Indemnity. (8) Date filed with Co. (9) Amount claimed.. (10) Composition of claim___ (Specify fully medical expenses, indemnification for wages, dam (20) Was claim adjusted prior to termination of disability. (21) If so, probable period of disability from date of adjustment_._. Additional Data. § 288. Nature and scope of act.-The law of this state covers nine extra hazardous employments. It abolishes the defense of fellow servant and assumed risk and substitutes the rule of comparative negligence for the old rule of contributory negligence. The employers are made directly liable for the compensation and medical and surgical aid. The scheme of administration provides for local boards of arbitration whose actions are subject to review by the courts. Benefits in death cases are three years' earnings with a minimum of $2,000 and a maximum of $3,000; and in case there are no dependents, $300. The compensation paid in case of partial and total disability begins ten days after the accident happened and continues so long as the disability lasts and is at the rate of 60 per cent. of the impairment of the injured worker's earning capacity, but in no case shall the compensation exceed $3,000. Medical and surgical aid are paid for by the employer only in case an employé dies of an injury covered by the act and without dependents. $289. Procedure-Boards of arbitration. The act does not provide for a board of administration. The law is presumed to work automatically. There is no formal procedure prescribed in the act, but the act does provide for the formation of local boards of arbitration by |