Log Of Work-Related Injuries And Illnesses - Bureau Of Labor Statistics
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4Attention: This form contains information relating to
OSHA’s Form 300
employee health and must be used in a manner that
(Rev. 01/2004)
Year 20__ __
protects the confidentiality of employees to the extent
possible while the information is being used for
Log of Work-Related Injuries and Illnesses
U.S. Department of Labor
occupational safety and health purposes.
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
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
Establishment name ___________________________________________
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.
City ________________________________ State ___________________
Identify the person
Describe the case
Classify the case
CHECK ONLY ONE box for each case
Enter the number of
(A)
(B)
(C)
(D)
(E)
(F)
Check the “Injury” column or
based on the most serious outcome for
days the injured or
ill worker was:
Case
Employee’s name
Job title
Date of injury
Where the event occurred
Describe injury or illness, parts of body affected,
that case:
choose one type of illness:
no.
(
e.g., Welder
)
(
e.g., Loading dock north end
)
and object/substance that directly injured
or onset
(M)
Remained at Work
or made person ill (
e.g., Second degree burns on
of illness
Away
On job
right forearm from acetylene torch
)
from
transfer or
Days away
Job transfer
Other record-
Death
from work
or restriction
able cases
work
restriction
(G)
(H)
(I)
(J)
(K)
(L)
(1)
(2)
(3)
(4) (5)
(6)
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days
days
month/day
Page totals
Be sure to transfer these totals to the Summary page (Form 300A) before you post it.
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
Page ____ of ____
(3)
(4) (5)
(6)
(1)
(2)
Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.
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