Spreadsheet: 38f65a27-f59b-4682-9726-8d2838fc64b6
Sheet: OSHA 300  (Pg1)

 |  |  |  |  |  | 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.
OSHA's Form 300 (Rev. 01/2004) |  |  |  |  |  |  |  |  |  |  |  | Year | 2012
Log of Work-Related Injuries and Illnesses |  |  |  |  |  |  |  |  |  |  | U.S. Department of Labor
 |  |  |  |  |  |  |  |  |  |  | Occupational Safety and Health Administration
You must record information 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 29 CFR 1904.8 through 1904.12.  Feel free to use two lines for a single case if you need to.  You must complete an injury and illness incident report (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, call your local OSHA office for help. |  |  |  |  |  |  |  |  |  |  |  | Form approved OMB no. 1218-0176
 |  |  |  |  |  |  |  | Establishment name
 |  |  |  |  |  |  |  | City |  |  |  | State | North Carolina
Identify the person |  | Describe the case |  |  |  | Classify the case
 |  |  |  |  |  | CHECK ONLY ONE box for each case based on the most serious outcome for that case: |  |  |  | Enter the number of days the injured or ill worker was: |  | Check the "injury" column or choose one type of illness:
(A) | (B) | (C) | (D) | (E) | (F)
Case No. | Employee's Name | Job Title  (e.g., [NAME]) | Date of injury or onset of illness | Where the event occurred (e.g. Loading dock north end) | Describe injury or illness, parts of body affected, and object/substance that directly injured or made person ill (e.g. Second degree burns on right forearm from acetylene torch)
 |  |  |  |  |  |  |  |  |  |  |  | (M) | [NAME] | Respiratory Condition | Poisoning | Hearing Loss | All other illnesses
 |  |  |  |  |  | Death | Days away from work | Remained at work |  | Away From Work (days) | On job transfer or restriction (days) | Injury
 |  |  | (mo./day)
 |  |  |  |  |  |  |  | Job transfer or restriction | Other record- able cases
 |  |  |  |  |  | (G) | (H) | (I) | (J) | (K) | (L) | (1) | (2) | (3) | (4) | (5) | (6)
 |  |  |  |  | Page totals
 |  |  |  |  | Be sure to transfer these totals to the [NAME] page (Form 300A) before you post it. |  |  |  |  |  |  | Injury | [NAME] | Respiratory Condition | Poisoning | Hearing Loss | All other illnesses
Public reporting burden for this collection of information is estimated to average 14 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.
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