Ask the Scholar
Page 3 of 3
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 Lummions Mature 11
Number arthur a Pritton
of
Month
166 alden Street
(Name of Employer)
(Street Address)
Orange (City or Town) ng
Date of Accident.
(Name of, Injured Employee)
21 Day of
253 are
Month
watching (Street Address)
1918
west Orange
(City or Town)
Hour 4+ P. M. M.
Pipefitter 3. (Occupation)
american
(Business)
4. (Nationality)
Date report received
Leave this line blank
1. State fully how accident occurred
5. Sex male 6. Age 26
7. Married yes
8. Give name of machine or appliance involved got a
nail in foot
9. Indicate kind of work done on this machine.
Pipe fitting in Jank house
2. Exact part of person injured, with nature and extent of injury
10. Name distinct part of machine causing injury
left foot
instep of
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?
street and number. Toukhonse#/
17. If the wages were fixed by the hour, state RATE per hour
13. Was medical attention necessary? yes
411rc
14. Name and address of attending physician 18.
Give number of HOURS in ordinary day. 44/2/W
15. If sent to hospital, Rond state name and location W,O,
19. Give number of DAYS in ordinary working week 6
20. State the amount of weekly WAGES 31.35
Date of preparing this blank
19
Made out by
Victor Rote
Fill in names and date on FORM "D" before detaching.
If employee has resumed work at time of reporting, do not detach.
Ryn
Number
11
of
arth Britton
(Name 166aldnt of Employer)
(Street address)
Date of Accident.
Month
(Name of Injured Employee)
n
Day of
Month Report received.
198
Leave this blank
Year
(City of town)
3days
34. If not able to work, give
#
30. Did employee lose any time?
probable date of recovery
31. Is employee able to resume work?
35. Has any permanent injury resulted? no
11-26-18
If so, describe fully on back of form.
32. If so, on what DATE?
36. Has your insurance carrier arranged to file the
days 3
compensation reports with the State for you?
33. State length of disability, weeks
Date of preparing this blank 11-27
1918
Made out by
If employee is still disabled at the time of preparing FORM "C," fill in names on this supplemental report, detach it and
forward same, duly completed, on the FOURTEENTH DAY after the day of the accident, or on the day the injured returns, if he
is able to work before the expiration of two weeks. If employee loses no time, or has returned to work at time of reporting, fill
out FORM "D," but do not detach.
This report of accident is to be prepared in DUPLICATE. Mail the original (if detached) to the Department of Labor,
Compensation Bureau, State House, Trenton, N. J. (carbon copy will not serve), and the duplicate copy to
NEW AMSTERDAM CASUALTY COMPANY.
When in need of blanks, apply to your insurance carrier.
FORM "D." SUPPLEMENTAL REPORT. For use of insuring employers.
Page data
- Page
- 3
- Source index
- 0
- Type
- document
- Media ID
- af5da88edbff99a7
- Size
- unknown
Document data
- ID
- 75718358
- Core
- doc
- Type
- document
DTO data
{
"id": "75718358",
"sourceUrl": "https://catalog.archives.gov/id/75718358",
"contentType": "document",
"title": "Accident report, November 27, 1918",
"citationUrl": "https://catalog.archives.gov/id/75718358",
"collections": [
"Safety Light Collection",
"Records Related to Radium Dial Painters"
],
"iiifBase": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000045_Page_1.jpg",
"thumbnailUrl": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000045_Page_1.jpg",
"largeImageUrl": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000045_Page_1.jpg",
"imageCount": 3,
"hasImages": true,
"source": "import",
"hasTranscription": false
}
Context sent to Scholar
Document identity
{
"localId": "75718358",
"label": "Accident report, November 27, 1918",
"core": "doc",
"dtoType": "document",
"citationUrl": "https://catalog.archives.gov/id/75718358"
}
Document source metadata
{
"id": "75718358",
"sourceUrl": "https://catalog.archives.gov/id/75718358",
"contentType": "document",
"title": "Accident report, November 27, 1918",
"citationUrl": "https://catalog.archives.gov/id/75718358",
"collections": [
"Safety Light Collection",
"Records Related to Radium Dial Painters"
],
"iiifBase": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000045_Page_1.jpg",
"thumbnailUrl": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000045_Page_1.jpg",
"largeImageUrl": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000045_Page_1.jpg",
"imageCount": 3,
"hasImages": true,
"source": "import",
"hasTranscription": false
}
Document source extras
{
"url": "https://catalog.archives.gov/id/75718358",
"naId": 75718358,
"levelOfDescription": "fileUnit",
"recordType": "description",
"ocrSource": "nara-archive"
}
Page context
{
"seq": 3,
"pageIndex": 0,
"type": "document",
"url": "https://s3.amazonaws.com/NARAprodstorage/lz/electronic-records/SLC/Radium/SLC_0000045.pdf",
"mediaId": "af5da88edbff99a7",
"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 Lummions Mature 11\nNumber arthur a Pritton\nof\nMonth\n166 alden Street\n(Name of Employer)\n(Street Address)\nOrange (City or Town) ng\nDate of Accident.\n(Name of, Injured Employee)\n21 Day of\n253 are\nMonth\nwatching (Street Address)\n1918\nwest Orange\n(City or Town)\nHour 4+ P. M. M.\nPipefitter 3. (Occupation)\namerican\n(Business)\n4. (Nationality)\nDate report received\nLeave this line blank\n1. State fully how accident occurred\n5. Sex male 6. Age 26\n7. Married yes\n8. Give name of machine or appliance involved got a\nnail in foot\n9. Indicate kind of work done on this machine.\nPipe fitting in Jank house\n2. Exact part of person injured, with nature and extent of injury\n10. Name distinct part of machine causing injury\nleft foot\ninstep of\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?\nstreet and number. Toukhonse#/\n17. If the wages were fixed by the hour, state RATE per hour\n13. Was medical attention necessary? yes\n411rc\n14. Name and address of attending physician 18.\nGive number of HOURS in ordinary day. 44/2/W\n15. If sent to hospital, Rond state name and location W,O,\n19. Give number of DAYS in ordinary working week 6\n20. State the amount of weekly WAGES 31.35\nDate of preparing this blank\n19\nMade out by\nVictor Rote\nFill in names and date on FORM \"D\" before detaching.\nIf employee has resumed work at time of reporting, do not detach.\nRyn\nNumber\n11\nof\narth Britton\n(Name 166aldnt of Employer)\n(Street address)\nDate of Accident.\nMonth\n(Name of Injured Employee)\nn\nDay of\nMonth Report received.\n198\nLeave this blank\nYear\n(City of town)\n3days\n34. If not able to work, give\n#\n30. Did employee lose any time?\nprobable date of recovery\n31. Is employee able to resume work?\n35. Has any permanent injury resulted? no\n11-26-18\nIf so, describe fully on back of form.\n32. If so, on what DATE?\n36. Has your insurance carrier arranged to file the\ndays 3\ncompensation reports with the State for you?\n33. State length of disability, weeks\nDate of preparing this blank 11-27\n1918\nMade out by\nIf employee is still disabled at the time of preparing FORM \"C,\" fill in names on this supplemental report, detach it and\nforward same, duly completed, on the FOURTEENTH DAY after the day of the accident, or on the day the injured returns, if he\nis able to work before the expiration of two weeks. If employee loses no time, or has returned to work at time of reporting, fill\nout FORM \"D,\" but do not detach.\nThis report of accident is to be prepared in DUPLICATE. Mail the original (if detached) to the Department of Labor,\nCompensation Bureau, State House, Trenton, N. J. (carbon copy will not serve), and the duplicate copy to\nNEW AMSTERDAM CASUALTY COMPANY.\nWhen in need of blanks, apply to your insurance carrier.\nFORM \"D.\" SUPPLEMENTAL REPORT. For use of insuring employers."
}