Oshas Form 300 – Fill Out and Use This PDF

OSHA’s Form 300 (Rev. 01/2004)

Log of Work-Related Injuries and Illnesses

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.

Year 20__ __

U.S. Department of Labor

Occupational Safety and Health Administration

You 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.

Form approved OMB no. 1218-0176

Establishment name ___________________________________________

City ________________________________ State ___________________

Identify the person				Describe the case
(A)	(B)	(C)		(D)	(E)	(F)
Case	Employee’s name	Job title		Date of injury	Where the event occurred	Describe injury or illness, parts of body affected,
no.		(e.g., Welder)		or onset	(e.g., Loading dock north end)	and object/substance that directly injured
				of illness		or made person ill (e.g., Second degree burns on
						right forearm from acetylene torch)

_____	________________________	____________	/___	__________________	__________________________________________________
			month/day
_____	________________________	____________	/___	___________________	__________________________________________________
			month/day
_____	________________________	____________	/___	___________________	__________________________________________________
			month/day
_____	________________________	____________	/___	___________________	__________________________________________________
			month/day
_____	________________________	____________	/___	___________________	__________________________________________________
			month/day
_____	________________________	____________	/___	___________________	__________________________________________________
			month/day
_____	________________________	____________	/___	___________________	__________________________________________________
			month/day
_____	________________________	____________	/___	___________________	__________________________________________________
			month/day
_____	________________________	____________	/___	___________________	__________________________________________________
			month/day
_____	________________________	____________	/___	___________________	__________________________________________________
			month/day
_____	________________________	____________	/___	___________________	__________________________________________________
			month/day
_____	________________________	____________	/___	___________________	__________________________________________________
			month/day
_____	________________________	____________	/___	__________________	__________________________________________________
			month/day

Classify the case

CHECK ONLY ONE box for each case based on the most serious outcome for that case:

Remained at Work

	Days away Job transfer Other record-
Death	from work or restriction able cases
(G)	(H)	(I)	(J)
■	■	■❑	■❑
❑	❑
■	■	■❑	■❑
❑	❑
■	■	■❑	■❑
❑	❑
■	■	■❑	■❑
❑	❑
■	■	■❑	■❑
❑	❑
■	■	■❑	■❑
❑	❑
■	■	■❑	■❑
❑	❑
■	■	■❑	■❑
❑	❑
■	■	■❑	■❑
❑	❑
■	■	■❑	■❑
❑	❑
■	■	■❑	■❑
❑	❑
■	■	■❑	■❑
❑	❑
■	■	■❑	■❑
❑	❑

Enter the number of days the injured or ill worker was:

Away	On job
from	transfer or
work	restriction

(K)(L)

____ days	____ days
____ days	____ days
____ days	____ days
____ days	____ days
____ days	____ days
____ days	____ days
____ days	____ days
____ days	____ days
____ days	____ days
____ days	____ days
____ days	____ days
____ days	____ days
____ days	____ days

Check the “Injury” column or choose one type of illness:

(M)	Skindisorder	Respiratory condition		Hearingloss
INJURY			Poisoning		Allother illnesses
(1)	(2)	(3)	(4)	(5)	(6)

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.

Page totals

Be sure to transfer these totals to the Summary page (Form 300A) before you post it.

Page ____ of ____

INJURY	Skindisorder	Respiratory condition	Poisoning	Hearingloss	Allother illnesses
(1)	(2)	(3)	(4)	(5)	(6)

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.

Number of Cases

Establishment information

Your establishment name __________________________________________

Street	_____________________________________________________
City	____________________________ State ______ ZIP _________

Total number of deaths

__________________

(G)

Total number of cases with days away from work

__________________

(H)

Total number of	Total number of
cases with job	other recordable
transfer or restriction	cases
__________________	__________________
(I)	(J)

Industry description (e.g., Manufacture of motor truck trailers)

_______________________________________________________

Standard Industrial Classification (SIC), if known (e.g., 3715)

____ ____ ____ ____

OR

North American Industrial Classification (NAICS), if known (e.g., 336212)

Number of Days

Total number of days away	Total number of days of job
from work	transfer or restriction
___________	___________

____ ____ ____ ____ ____ ____

Employment information (If you don’t have these figures, see the Worksheet on the back of this page to estimate.)

Annual average number of employees

______________

(K)

Injury and Illness Types

Total number of . . .

	(M)
(1)	Injuries	______
(2)	Skin disorders	______
(3)	Respiratory conditions	______

(L)

(4)	Poisonings	______
(5)	Hearing loss	______
(6)	All other illnesses	______

Total hours worked by all employees last year ______________

Sign here

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

OSHA’s Form 301

Injury and Illness Incident Report

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 and use as many as you need.

Completed by _______________________________________________________
Title _________________________________________________________________
Phone (________)_________--_____________	Date _____/ _____ / _____

Information about the employee

1)Full name _____________________________________________________________

2)Street ________________________________________________________________

City ______________________________________ State _________ ZIP ___________

3)Date of birth ______ / _____ / ______

4)Date hired ______ / _____ / ______

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 _______________________________________________________________

City ______________________________________ State _________ ZIP ___________

8)Was employee treated in an emergency room?

Yes

No

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

Yes

No

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	______ / _____ / ______
12)	Time employee began work ____________________		AM / PM
13)	Time of event	____________________	AM / PM Check if time cannot be determined

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; be more specific than “hurt,” “pain,” or sore.” Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.”

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 ______ / _____ / ______