Osha'S Form 300a (Rev. 01/2004) Summary Of Work-Related Injuries And Illnesses
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1OSHA's Form 300A
(Rev. 01/2004)
Year
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 injuries or illnesses
occurred during the year. Remember to review the Log to verify that the entries are complete and accurate
Establishment information
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
Your establishment name
entirety. They also have limited access to the OSHA Form 301 or its equivalent. See 29 CFR 1904.35, in
OSHA's Recordkeeping rule, for further details on the access provisions for these forms.
Street
City
State
Zip
Number of Cases
Industry description (e.g., Manufacture of motor truck trailers)
Total number of
Total number of
Total number of cases
Total number of
deaths
cases with days
with job transfer or
other recordable
away from work
restriction
cases
Standard Industrial Classification (SIC), if known (e.g., SIC 3715)
0
0
0
0
(G)
(H)
(I)
(J)
OR
North American Industrial Classification (NAICS), if known (e.g., 336212)
Number of Days
Employment information
Total number of
Total number of days of
days away from
job transfer or restriction
Annual average number of employees
work
Total hours worked by all employees last
0
0
year
(K)
(L)
Injury and Illness Types
Sign here
Total number of…
Knowingly falsifying this document may result in a fine.
(M)
(1) Injury
0
(4) Poisoning
0
(2) Skin Disorder
0
(5) Hearing Loss
0
I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and
(3) Respiratory
complete.
Condition
0
(6) All Other Illnesses
0
Title
Company executive
Post this Summary page from February 1 to April 30 of the year following the year covered by the form
Phone
Date
Public reporting burden for this collection of information is estimated to average 58 minutes per response, including time to review the instruction, 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 aspects of this data collection, contact: US Department of Labor,
OSHA Office of Statistics, Room N-3644, 200 Constitution Ave, NW, Washington, DC 20210. Do not send the completed forms to this office.
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