Ask the Scholar
Page 2 of 2
I can add historical knowledge about this page.
Page image
OCR
Form 3865-N. J.
STATE OF NEW JERSEY, ACCIDENT BLANK.
Report Every Accident Immediately.
This report of accident is to be prepared in DUPLICATE. The original is to be sent to the Department of Labor, Bureau
of Industrial Statistics, State House, Trenton, N. J. Carbon copy will not serve. The other copy is to be sent to
New Amsterdam Casualty Company
59 JOHN STREET
EXECUTIVE
7 ST. PAUL ST,
NEW YORK, N.Y.
OFFICES
BALTIMORE MD.
FORM "C." First notice of Accident. For use by insuring employers.
Radium Lominous Material
11
Number Month Martin Bagdan
of
(Name of Employer)
Orange N.J.
Date of Accident.
(Name of Injured Employee)
166 Alden Street
11 Day Month of IbLlewelyn Fivenue
(Street Address)
(Street Address)
1918
Year
West
(City or Town)
Orange (City or Town)
Chemical Plant
10- A. M. M.
Fireman
Russian
(Business)
Hour
3. (Occupation)
4. (Nationality)
Date report received
Leave this line blank
1. State fully how accident occurred
5. Sex male 6. Age 45 7. Married yes
8. Give name of machine or appliance involved
Bruised left hand
9. Indicate kind of work done on this machine
working in Boilerhouse
2. Exact part of person injured, with nature and extent of injury 10. Name distinct part of machine causing injury
left hand, slightly
bruised
11. Was any guard protecting this portion of the machine?
12. Exact location of accident. If away from plant, give town, 16. Were the wages fixed by the output? no
street and number
Boiler house
17. If the wages were fixed by the hour, state RATE per hour
13. Was medical attention necessary
yes.
49½ & perh.
18. Give number of HOURS in ordinary day
14 hours
14. Name and address of attending physician Dr. Dowling
19. Give number of DAYS in ordinary working week 6
15. If sent to hospital, state name and location
20. State the amount of weekly WAGES 4100
Date of preparing this blank Nov 11-
1919
Made out by
Roth
Fill in names and date on FORM "D" before detaching.
If employee has resumed work at time of reporting, do not detach.
Page data
- Page
- 2
- Source index
- 0
- Type
- document
- Media ID
- e7827b99c66ccd42
- Size
- unknown
Document data
- ID
- 75718352
- Core
- doc
- Type
- document
DTO data
{
"id": "75718352",
"sourceUrl": "https://catalog.archives.gov/id/75718352",
"contentType": "document",
"title": "Accident report, November 11, 1918",
"citationUrl": "https://catalog.archives.gov/id/75718352",
"collections": [
"Safety Light Collection",
"Records Related to Radium Dial Painters"
],
"iiifBase": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000043.jpg",
"thumbnailUrl": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000043.jpg",
"largeImageUrl": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000043.jpg",
"imageCount": 2,
"hasImages": true,
"source": "import",
"hasTranscription": false
}
Context sent to Scholar
Document identity
{
"localId": "75718352",
"label": "Accident report, November 11, 1918",
"core": "doc",
"dtoType": "document",
"citationUrl": "https://catalog.archives.gov/id/75718352"
}
Document source metadata
{
"id": "75718352",
"sourceUrl": "https://catalog.archives.gov/id/75718352",
"contentType": "document",
"title": "Accident report, November 11, 1918",
"citationUrl": "https://catalog.archives.gov/id/75718352",
"collections": [
"Safety Light Collection",
"Records Related to Radium Dial Painters"
],
"iiifBase": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000043.jpg",
"thumbnailUrl": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000043.jpg",
"largeImageUrl": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000043.jpg",
"imageCount": 2,
"hasImages": true,
"source": "import",
"hasTranscription": false
}
Document source extras
{
"url": "https://catalog.archives.gov/id/75718352",
"naId": 75718352,
"levelOfDescription": "fileUnit",
"recordType": "description",
"ocrSource": "nara-archive"
}
Page context
{
"seq": 2,
"pageIndex": 0,
"type": "document",
"url": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000043.pdf",
"mediaId": "e7827b99c66ccd42",
"ocrText": "Form 3865-N. J.\nSTATE OF NEW JERSEY, ACCIDENT BLANK.\nReport Every Accident Immediately.\nThis report of accident is to be prepared in DUPLICATE. The original is to be sent to the Department of Labor, Bureau\nof Industrial Statistics, State House, Trenton, N. J. Carbon copy will not serve. The other copy is to be sent to\nNew Amsterdam Casualty Company\n59 JOHN STREET\nEXECUTIVE\n7 ST. PAUL ST,\nNEW YORK, N.Y.\nOFFICES\nBALTIMORE MD.\nFORM \"C.\" First notice of Accident. For use by insuring employers.\nRadium Lominous Material\n11\nNumber Month Martin Bagdan\nof\n(Name of Employer)\nOrange N.J.\nDate of Accident.\n(Name of Injured Employee)\n166 Alden Street\n11 Day Month of IbLlewelyn Fivenue\n(Street Address)\n(Street Address)\n1918\nYear\nWest\n(City or Town)\nOrange (City or Town)\nChemical Plant\n10- A. M. M.\nFireman\nRussian\n(Business)\nHour\n3. (Occupation)\n4. (Nationality)\nDate report received\nLeave this line blank\n1. State fully how accident occurred\n5. Sex male 6. Age 45 7. Married yes\n8. Give name of machine or appliance involved\nBruised left hand\n9. Indicate kind of work done on this machine\nworking in Boilerhouse\n2. Exact part of person injured, with nature and extent of injury 10. Name distinct part of machine causing injury\nleft hand, slightly\nbruised\n11. Was any guard protecting this portion of the machine?\n12. Exact location of accident. If away from plant, give town, 16. Were the wages fixed by the output? no\nstreet and number\nBoiler house\n17. If the wages were fixed by the hour, state RATE per hour\n13. Was medical attention necessary\nyes.\n49½ & perh.\n18. Give number of HOURS in ordinary day\n14 hours\n14. Name and address of attending physician Dr. Dowling\n19. Give number of DAYS in ordinary working week 6\n15. If sent to hospital, state name and location\n20. State the amount of weekly WAGES 4100\nDate of preparing this blank Nov 11-\n1919\nMade out by\nRoth\nFill in names and date on FORM \"D\" before detaching.\nIf employee has resumed work at time of reporting, do not detach."
}