California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 7 - Department of Industrial Relations › Subchapter 1 - Occupational Injury or Illness Reports and Records › Article 2 - Employer Records of Occupational Injury or Illness › Appendix D - Required Elements for the Cal/OSHA 300 Equivalent Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
I. California employers who are required to record
						work-related injuries and illnesses on the Cal/OSHA Form 300 may use an
						equivalent form that includes all of the following instructions and
						information.
Log of Work-Related Injuries and Illnesses
Instruction: You must record information about every
						work-related death and about every work-related injury or illness that involves
						loss of consciousness, restricted work activity or job transfer, days away from
						work, or medical treatment beyond first aid. You must also record significant
						work-related injuries and illnesses that are diagnosed by a physician or
						licensed health care professional. You must also record work-related injuries
						and illnesses that meet any of the specific recording criteria listed in
						8 CCR
						14300.8 through
						14300.12. Feel free to use two
						lines for a single case if you need to. You must complete an Injury and Illness
						Incident Report (Cal/OSHA Form 301) or equivalent form for each injury or
						illness recorded on this form. If you're not sure whether a case is recordable,
						contact the nearest office of the Division of Occupational Safety and Health
						for assistance.
Establishment Name & Address
Identify the Person (A)-(C)
A. Case Number
B. Employee's Name
C. Job Title
Describe the Case (D)-(F):
D. Date of Injury or illness
E. Where the event occurred
F. Describe the injury or illness, part(s) of the body
						affected, and object/substance that directly injured or made the person
						ill
Classify the Case (G)-(M)
Using these four categories (G)-(J), indicate only the
						most serious result for each case:
G. "Death"
H. "Days away from work"
I. Remained at work as "Other recordable cases"
J. Remained at work with "Job transfer or
						restriction"
Enter the number of days the injured or ill worker
						was:
K. Number of days the injured or ill worker was "Away
						from work"
L. Number of days the injured or ill worker was "On job
						transfer or restrictions"
M. Indicate an injury or, one type of illness:
(1) Injury column
(2) Skin disorder column
(3) Respiratory condition column
(4) Poisoning column
(5) Occupational hearing loss
(6) All other illnesses column
Page Totals (for columns (G)-(M))
Instruction: Transfer these totals to the Summary page
						(Cal/OSHA Form 300A) before you post it.
Instructions for privacy concerns:
"ATTENTION: This form contains information relating to
						employee health and must be used in a manner that protects the confidentiality
						of employees to the extent possible while the information is being used for
						occupational safety and health purposes."
NOTE: Privacy Concern Cases: employers using forms
						equivalent to the Cal/OSHA 300 are required to follow the privacy concern
						disclosure restrictions specified in Section
						14300.29(b)(6)-(10).
NOTE: Additional Criteria. Beginning January 1, 2002,
						employers are required to record the following as specific injury and illness
						conditions. These are:
1. Injury from a needle or other sharp object that is
						contaminated with blood or OPIM (Reference: Section
						14300.8)
2. Cases of medical removal under the requirements of a
						Cal/OSHA standard. (Reference: Section
						14300.9)
3. Tuberculosis infection as evidenced by a positive skin
						test or diagnosis by a physician. (Reference: Section
						14300.11)
Note: Authority cited: Section
						  6410, Labor
						  Code. Reference: Section
						  6410, Labor
						  Code; and 29 Code of Federal Regulations Section
						  1904.10.