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U .S. De pa rt m e nt of La borOc c upa t iona l Sa fe t y a nd H e a lt h Adm inist ra t ion
OSHA’s Form 300 (Rev. 01/2004)Year 20Log of Work -Re la t e d
I njurie s a nd I llne sse sYou 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 29 CFR Part 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.
Page
Inju
ry
Skin
dis
orde
r
Res
pira
tory
co
nditi
on
Pa ge t ot a ls
Establishment name
City
Ent e r t he num be r of da ys t he injure d or ill w ork e r w a s:
Se le c t t he “I njury” c olum n or c hoose one t ype of illne ss:
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.
(A) (B) (C) (D) (E) (F)
(M)
(K) (L)(G) (H) (I) (J)De a t h
Da ys a w a y from w ork
On job t ra nsfe r or re st ric t ion
Aw a y from w ork
At t e nt ion: 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.
SELECT ON LY ON E box for e a c h c a se ba se d on t he m ost se rious out c om e for t ha t c a se :
J ob t ra nsfe r or re st ric t ion
Ot he r re c ord- a ble c a se s
Re m a ine d a t Work
(1) (2) (3) (4) (5) (6)
(1) (2) (3) (4) (5) (6)
Case no.
Job title (e.g., Welder)
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)
Date of injury or onset of illness (e.g., 2/10)
I de nt ify t he pe rson De sc ribe t he c a se Cla ssify t he c a se
Employee’s name
Pois
onin
g
Hea
ring
loss
All
othe
r ill
ness
es
W
All
othe
r ill
ness
es
Hea
ring
loss
Pois
onin
g
Res
pira
tory
co
nditi
on
Skin
dis
orde
r
Inju
ry
Form approved OMB no. 1218-0176
State
CSU Widget Factory
of
N ot e : Y ou c a n t ype input int o t his form a nd sa ve it . Because the forms in this recordkeeping package are “fillable/writable” PDF documents, you can type into the input form fields and then save your inputs using the free Adobe PDF Reader. In addition, the forms are programmed to auto-calculate as appropriate.
0 3 0 0 8 14 2 0 1 0 0 0
1 1Save Input Add a Form Page
OSHA’s Form 300A (Rev. 01/2004)Sum m a ry of Work -Re la t e d I njurie s a nd I llne sse s
Form approved OMB no. 1218-0176
Total number of deaths
Total number of cases with days away from work
N um be r of Ca se s
Total number of days away from work
Total number of days of job transfer or restriction
N um be r of Da ys
Post t his Sum m a ry pa ge from Fe brua ry 1 t o April 3 0 of t he ye a r follow ing t he ye a r c ove re d by t he form .
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.
Est a blishm e nt inform a t ionY our e st a blishm e nt na m e
Street
City
Industry description (e.g., Manufacture of motor truck trailers)
Standard Industrial Classification (SIC), if known (e.g., 3715)
Public reporting burden for this collection of information is estimated to average 50 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.
Total number of . . .
Skin disorders
Respiratory conditions
Injuries
I njury a nd I llne ss T ype s
Poisonings
Hearing loss
All other illnesses
(G) (H) (I) (J)
(K) (L)
(M)
(1)
(2)
(3)
(4)
(5)
(6)
Total number of cases with job transfer or restriction
Total number of other recordable cases
U .S. De pa rt m e nt of La borOc c upa t iona l Sa fe t y a nd H e a lt h Adm inist ra t ion
Year 20
OR
North American Industrial Classification (NAICS), if known (e.g., 336212)
Em ploym e nt inform a t ion (If you don't have these figures, see the Worksheet on the next page to estimate.)
Annual average number of employees
Total hours worked by all employees last year
Sign he re
Knowingly falsifying this document may result in a fine.
I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete.
________________________________ ___________________ Company executive Title
Phone ______ – _______ – ___________ Date _____ / _____ / ______
0
N ot e : Y ou c a n t ype input int o t his form a nd sa ve it . Because the forms in this recordkeeping package are “fillable/writable” PDF documents, you can type into the input form fields and then save your inputs using the free Adobe PDF Reader.
State Zip
0
8
0
0
Save Input
0 3 0 0
14
2
1
CSU Widget Factory
21982 University LaneOrange Beach AL 36561
Widget Manufacturing
326199
2758675
