U.S. Department of Labor

Bureau of Labor Statistics

Supplementary Record of

Occupational Injuries and Illnesses

This form is required by Public Law 91-506 and must be kept in the establishment for 5 years.  Failure to maintain can result in the issuance of citations and assessment of penalties.

Case or File No.

          Form Approved
O.M.B. No. 1220 0029

Employer

   1.  Name: Quality Choice Construction, LLC.

   2.  Mail address (No. and street, city or town, State, and zip code)

 2775 South Nellis Blvd. - Suite #10 - LasVegas, NV  89121

   3.  Location, if different from mail address: Site Location (if applicable)

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.  Age

7.  Sex: (Check one)

                                                Male  q       Female  q

   8.  Occupation (Enter regular job title, not the specific activity he was performing at time of injury.)

   9.  Department (Enter name of department or division in which the injured person is regularly employed, even though
       he may have been temporarily working in another department at the time of injury.)

The Accident or Exposure to Occupational Illness

   If accident or exposure occurred on employer’s premises, give address of plant or establishment in which it occurred.
   Do not indicate department or division within the plant or establishment.  If accident occurred outside employer’s
   premises at an identifiable address, give that address.  If it occurred on a public highway or at any other place which
   cannot be identified by number and street, please provide place references locating the place of injury as accurately as
   possible.

   10.  Place of accident or exposure (No. and street, city or town, State, and zip code)

   11.  Was place of accident or exposure on employer’s premises?

                                                                                                                Yes  q       No  q 

   12.  What was the employee doing when injured? (Be specific.  If he was using tools or equipment or handling material,

          name them and tell what he was doing with them.)

   13.  How did the accident occur?  (Describe fully the events which resulted in the injury or occupational illness.  Tell )

          what happened. Name any objects or substances involved and tell how they were involved.  Give full details on all

          factors which led or contributed to the accident.  Use separate sheet for additional space.)

Occupational Injury or Occupational Illness

   14.  Describe the injury or illness in detail and indicate the part of body affected. (E.g., amputation of right index finger
         at second joint; fracture of ribs; lead poisoning; dermatitis of left hand, etc.)

   15.  Name the object or substance which directly injured the employee.  (For example, the machine or thing he struck
          against or which struck him; the vapor or poison he inhaled or swallowed; the chemical or radiation which irritated
          his skin; or in cases or strains, hernias, etc., the thing he was lifting, pulling, etc.)

   16.  Date of injury or initial diagnosis of occupational illness

17.  Did employee die? (Check one)

                                                             Yes  q       No  q

Other

   18.  Name and address of physician

   19.  If hospitalized, name and address of hospital

Date of Report

Prepared by

Official position

OSHA No. 101 (Feb. 1981)

For Calendar Year 2002

Page _1__ of _1__

^{Company Name:  Quality Choice Construction, LLC.}

_{Form Approved}

^{Establishment Name}

^{O.M.B. No. 1220-0029}

^{Establishment Address: 2775 South Nellis Blvd.  Suite #10,  Las Vegas, NV  89121}

^{Extent of and Outcome of INJURY}

^{Type, Extent of, and Outcome of ILLNESS}

^Fatalities

^{Nonfatal Injuries}

^{Type of Illness}

^Fatalities

^{Nonfatal Illness}

Injury
Related

Injuries With Lost Workdays

Injuries Without Lost Workdays

CHECK Only One Column for Each Illness (See other side of form for terminations or permanent transfers.)

Illness Related

Illnesses With Lost Workdays

Illnesses Without Lost Workdays

Enter DATE of death.



Mo./day/yr.

Enter a CHECK if injury involves days away from work, or days of restricted work activity, or both.

Enter a CHECK if injury involves days away from work.

Enter number of DAYS away from work.

Enter number of DAYS of restricted work activity.

Enter a CHECK if no entry was made in columns 1 or 2 but the injury is re-cordable as defined above.

Enter DATE of death.





Mo./day/yr.

Enter a CHECK if illness involves days away from work, or days of restricted work activity, or both.

Enter a CHECK if illness involved days away from work.

Enter num-ber of DAYS away from work.

Enter number of DAYS of re-stricted work activity.

Enter a CHECK if no entry was made in columns 8 or 9.

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)

(a)

(b)

(c)

(d)

(e)

(f)

(g)

   Certification of Annual Summary Totals By ___________________________________________________        Title ______________________________________      Date __________________

   OSHA No. 200                                               POST ONLY THIS PORTION  OF THE LAST PAGE NO LATER THAN FEBRUARY 1.