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Get Occupational Safety And Health Act (united States) - Wikipedia

Establishment for 5 years. Case or File No. Failure to maintain can result in the issuance of citations and assessment of penalties. Form Approved O.M.B. No. 1218-0176 Employer See OMB Disclosure 1. Name Statement on reverse. 2. Mail address (No. and street, city or town, State, and zip code) 3. Location, if different from mail address Injured or Ill Employee 4 Name (First, middle, and last) Social Security No. 5. Home address (No. and street, city or town, State, and zip code) 6.

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