Osha Form 301 Incident Report

Attention: This form contains information relating to

OSHA’s Form 301

employee health and must be used in a manner that

protects the confidentiality of employees to the extent

Injury and Illness Incident Report

possible while the information is being used for

U.S. Department of Labor

occupational safety and health purposes.

Occupational Safety and Health Administration

Form approved OMB no. 1218-0176

Information about the employee

Information about the case

This

Injury and Illness Incident Report

is one of the

1)

Full name

_____________________________________________________________

10)

Case number from the

Log

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

first forms you must fill out when a recordable work-

related injury or illness has occurred. Together with

11)

Date of injury or illness

______ / _____ / ______

2)

Street

________________________________________________________________

the

Log of Work-Related Injuries and Illnesses

and the

Time employee began work

____________________

AM / PM

12)

accompanying

Summary,

these forms help the

0

City

______________________________________

State

_________

ZIP

___________

13)

____________________

Time of event

AM / PM

Check if time cannot be determined

employer and OSHA develop a picture of the extent

and severity of work-related incidents.

3)

Date of birth

______ / _____ / ______

14)

Describe the activity, as well as the

What was the employee doing just before the incident occurred?

Within 7 calendar days after you receive

tools, equipment, or material the employee was using. Be specific.

Examples:

“climbing a ladder while

4)

Date hired

______ / _____ / ______

carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.”

information that a recordable work-related injury or

r

5)

Male

illness has occurred, you must fill out this form or an

r

Female

equivalent. Some state workers’ compensation,

insurance, or other reports may be acceptable

substitutes. To be considered an equivalent form,

Tell us how the injury occurred.

Examples:

“When ladder slipped on wet floor, worker

15)

What happened?

Information about the physician or other health care

any substitute must contain all the information

fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker

professional

asked for on this form.

developed soreness in wrist over time.”

According to Public Law 91-596 and 29 CFR

6)

Name of physician or other health care professional

__________________________

1904, OSHA’s recordkeeping rule, you must keep

this form on file for 5 years following the year to

________________________________________________________________________

which it pertains.

16)

Tell us the part of the body that was affected and how it was affected; be

7)

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

What was the injury or illness?

If you need additional copies of this form, you

more specific than “hurt,” “pain,” or sore.”

Examples:

“strained back”; “chemical burn, hand”; “carpal

may photocopy and use as many as you need.

Facility

_________________________________________________________________

tunnel syndrome.”

Street

_______________________________________________________________

______________________________________

_________

___________

City

State

ZIP

Examples:

“concrete floor”; “chlorine”;

What object or substance directly harmed the employee?

17)

8)

Was employee treated in an emergency room?

“radial arm saw.”

If this question does not apply to the incident, leave it blank.

r

Yes

Completed by

_______________________________________________________

r

No

9)

Was employee hospitalized overnight as an in-patient?

Title

_________________________________________________________________

r

Yes

r

No

Phone

Date

(________)_________--_____________

_____/ _ _____ / _____

If the employee died, when did death occur?

______ / _____ / ______

18)

Date of death

Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Persons are not required to respond to the

collection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Avenue, NW,

Washington, DC 20210. Do not send the completed forms to this office.