Osha Form 301 - Injury And Illness Incident Report

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OSHA Form 301- Injury and Illness Incident Report
Case #_____________
Recordable
Non- recordable
To be completed by EH&S
Information about the injured person
19) Did injured person file a Labor & Industries report?
Claim #__________________________
Yes
No
1) Full name:
_____________________________________________________
20) If the injured person died, Date of death: __________________
2) Street
_________________________________________________________
21) Location ____________________________________________________________
City
State
Zip
___________________________
_________
_______________
22) Witness: _____________________________________________________________
3) Injured persons "A" #________________________
23) What was the injured person doing just before the incident occurred? Describe the activity, as
4) Date of birth _______________ Date hired _______________
well as the tools, equipment, or material the injured person was using. Be specific. Examples:
5) Male
Female
"climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily
6) Employee
computer key-entry.
Job title__________________________________________________
Hrs/day________ Days/Wk_______
Student
Visitor
7) Program area ____________________ Phone #__________________
8) Injured persons Signature ____________________________________
9) Supervisor_________________________ Phone #________________
24) What happened? Tell us how the injury occurred. Examples: "When the ladder slipped on
wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during
Signature ______________________________ Date ____________
replacement"; "Worker developed soreness of wrist over time."
Information about the Medical Treatment
First Aid
Medical Treatment
10) Extent of treatment:
None
11) If treatment was given away from the worksite, where was it given?
Dr. Name ___________________________________________________
Facility _____________________________________________________
Street ______________________________________________________
25) What was the injury or illness? Tell us the part of the body that was affected and how it was
City__________________________ State __________ Zip ___________
affected; be more specific than "hurt," "pain," or "sore." Examples: "strained back"; "chemical burn,
hand"; "carpal tunnel syndrome."
12) Was the Injured person treated in an emergency room?
Yes
No
13) Was the Injured person hospitalized overnight as an in-patient?
Yes
No
Information about the case
26) What object or substance directly harmed the injured person? Examples: "concrete floor";
"chlorine"; "radial arm saw". If this question does not apply to the incident, leave it blank.
14) Date of injury or illness __________________
PM
AM
Unknown
15) Time of event :________
AM
PM
16) Time Injured person began work____________
17) Dates lost from work: __________________ to ________________
18) Dates on restricted duty: _______________ to _______________
Completed by:______________________________
Title: _______________________________________
Phone: ___________________________
Date: __________________
Attention: This form contains information relating to Injured
persons health and must be used in a manner that protects the
confidentiality of the information while being used for
Mark part of body injured on diagram above
occupational safety and health purposes to the extent possible .
Complete this form for all injuries and illnesses. When complete, print form, get necessary signatures, & make two photocopies. Forward the original to the EH&S Coordinator in 1254
LAB II and forward a photocopy to Business Services L 1125. The affected person keeps the remaining photocopy. This form should be completed within 24 hours of the incident.

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