Spreadsheet: 38f65a27-f59b-4682-9726-8d2838fc64b6
Sheet: OSHA Summary Form 300A

NC Division of Water Quality Combined Injury Listing
OSHA's Form 300A (Rev. 01/2004) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Year | 2012
Summary of Work-Related Injuries and Illnesses |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | U.S. Department of Labor
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Occupational Safety and Health Administration
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Form approved OMB no. 1218-0176
All establishments covered by Part 1904 must complete this Summary page, even if no injuries or illnesses occurred during the year.  Remember to review the Log to verify that the entries are complete and accurate before completing this summary.
Using the Log, count the individual entries you made for each category.  Then write the totals below, making sure you've added the entries from every page of the log.  If you had no cases write "0." |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Establishment information
Employees former employees, and their representatives have the right to review the OSHA Form 300 in its entirety.  They also have limited access to the OSHA Form 301 or its equivalent.  See 29 CFR 1904.35, in OSHA's Recordkeeping rule, for further details on the access provisions for these forms. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Your establishment name
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Street
Number of Cases |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | City |  |  |  |  |  |  |  |  |  |  | State |  | NC |  |  |  | Zip
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Industry description (e.g., Manufacture of motor truck trailers)
Total number of deaths |  | Total number of cases with days away from work |  | Total number of cases with job transfer or restriction |  | Total number of other recordable cases
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Standard Industrial Classification (SIC), if known (e.g., SIC 3715)
(G) |  | (H) |  | (I) |  | (J) |  |  |  |  |  |  |  |  | OR | North American Industrial Classification (NAICS), if known (e.g., 336212)
Number of Days |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Employment information
Total number of days away from work |  |  |  | Total number of days of job transfer or restriction
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Annual average number of employees
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total hours worked by all employees last year
(K) |  |  |  | (L)
Injury and Illness Types
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Sign here
Total number of… |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Knowingly falsifying this document may result in a fine.
(M)
(1)  Injury |  |  |  | (4)  Poisoning
(2)  [NAME] |  |  |  | (5)  Hearing Loss |  |  |  |  |  |  |  |  |  |  |  | I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete.
(3)  Respiratory Condition |  |  |  | (6) All Other Illnesses
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Company executive |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Title
Post this Summary page from February 1 to April 30 of the year following the year covered by the form |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Phone |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date
Public reporting burden for this collection of information is estimated to average 50 minutes per response, including time to review the instruction, search and gather the data needed, and complete and review the collection of information.  Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number.  If you have any comments about these estimates or any aspects of this data collection, contact:  US Department of Labor, OSHA Office of Statistics, [NAME], 200 Constitution Ave, NW, Washington, DC 20210.  Do not send the completed forms to this office.