■ ■ ■❑ ■❑ / ■ ■ ■❑ ■❑ / ■ ■ ■ ■ month/day / ■❑ ■❑ ■❑ ■❑ month/day days days days days days days days days days days days days Page totals Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review the instructions, 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 other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office. Be sure to transfer these totals to the Summary page (Form 300A) before you post it. Page of (1) (2) (3) (4) (5) (6)
OSHA’s Form 300A (Rev. 01/2004) Year 20 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 work-related 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.” 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 Part 1904.35, in OSHA’s recordkeeping rule, for further details on the access provisions for these forms. 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 (G) (H) (I) (J) number of days away from work Total number of days of job transfer or restriction (K) (L) Total number of... (M) Injuries Skin disorders Respiratory conditions Poisonings Hearing loss All other illnesses Post this Summary page from February 1 to April 30 of the year following the year covered by the form. Public reporting burden for this collection of information is estimated to average 58 minutes per response, including time to review the instructions, 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 other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.
OSHA’s Form 301 Injury and Illness Incident Report Department of Occupational Safety and Health Administration Information about the employee Information about the case Form approved OMB no. 1218-0176 Full name Street Case number from the Log (Transfer the case number from the Log after you record the case.) Date of injury or illness / / Time employee began work City State ZIP 13) Time of event AM / PM AM / PM Check if time cannot be determined Date of birth / / Date hired / / What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: “climbing a ladder while carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.” 5) O O Male Female Information about the physician or other health care professional Name of physician or other health care professional If treatment was given away from the worksite, where was it given? Facility Street City State ZIP Was employee treated in an emergency room? What happened? Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker developed soreness in wrist over time.” What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than “hurt,” “pain,” or sore.” Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.” What object or substance directly harmed the employee? Examples: “concrete floor”; “chlorine”; “radial arm saw.” If this question does not apply to the incident, leave it blank. O Yes O No 9) Was employee hospitalized overnight as an in-patient? O Yes O No If the employee died, when did death occur? Date of death / /