Osha Form 301 – Fill Out and Use This PDF

OSHA’S FORM 301 (Rev. 04/2004)

Injury and Illness Incident Report

Note: You can type input into this form and save 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.

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.

U.S. Department of Labor

Occupational Safety and Health Administration

This Injury and Illness Incident Report is one of the first forms you must fill out when a recordable work-related injury or illness has occurred. Together with the Log of Work-Related Injuries and Illnesses and the accompanying Summary, these forms help the employer and OSHA develop a picture of the extent and severity of work-related incidents.

Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out this form or an equivalent. Some state workers’ compensation, insurance, or other reports may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the information asked for on this form.

According to Public Law 91-596 and 29 CFR 1904, OSHA’s recordkeeping rule, you must keep this form on file for 5 years following the year to which it pertains.

If you need additional copies of this form, you

may photocopy the printout or insert additional form pages in the PDF, and then use as many as you need.

Information about the employee

1)Full name

2)Street

City		State		ZIP

3) Date of birth

Month Day Year

4)Date hired

Month Day Year

5) Male Female

Information about the physician or other health care professional

6)Name of physician or other health care professional

7)If treatment was given away from the worksite, where was it given?

Facility

Street

Form approved OMB no. 1218-0176

Information about the case

10) Case number from the LOG

(Transfer the case number from the Log after you record the case.)

11)Date of injury or illness

Month

Day

Year

12)

Time employee began work (HH:MM)

AM

PM

13)

Time of event (HH:MM)

AM

PM

Check if time cannot be determined

*Re fields 14 to 17: Please do not include any personally identifiable information (PII) pertaining to worker(s) involved in the incident (e.g., no names, phone numbers, or Social Security numbers).

14)* 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.”

15)* 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.”

16)* What was the injury or illness? Tell us the part of the body that was affected and how it was affected. Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.”

Completed by

Title

PhoneDate

Month Day Year

City		State		ZIP

8)Was employee treated in an emergency room?

Yes

No

9)Was employee hospitalized overnight as an in-patient?

Yes

No

17)* 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.

18) If the employee died, when did death occur? Date of death

		Month Day		Year
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