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| Inspection Nr | 302133061 |
| Investigation Nr | 200021319 |
| Line Nr | 3 |
| Age | |
| Sex | |
| Nature of Injury | Concussion |
| Part of Body | Multiple |
| Source of Injury | Dirt/Sand/Stone |
| Event Type | Fall(From Elevation) |
| Environmental Factor | Work-Surface/Facil-Layout Cond |
| Human Factor | Misjudgment, Haz. Situation |
| Occupation | Roofers |
| Degree of Injury | Hospitalized injury |
| Task Assigned | Task regularly assigned |
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