Osha Form 301 - Accident Report Form
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1For Office Use Only
Cannon Cochran Management Services, Inc. (CCMSI)
Accident Report
Claim #:
100 Quannapowitt Parkway, Suite 201
OSHA Form 301
Priors:
YES
NO
Wakefield, MA 01880
Please print clearly or type
CCMSI (781)-683-1000
Fax (781) 246-3425
TO BE COMPLETED BY INJURED EMPLOYEE
Name
Home Telephone Number
(
)
Home Address
Work Telephone Number
(
)
City
State
Zip
Date of Birth
/
/
Harvard ID Number
Gender
Time of Injury
am/pm
Time Shift Started
Time Shift Ended
Male
am/pm
am/pm
Date of Injury
Female
Check if cannot be determined
Building (example: Holyoke Center or Gordon Hall)
Specific location where injury occurred
What were you doing immediately prior to the injury?
[Describe the activity, as well as the tools, equipment, or material being used. Be specific. Examples: "climbing a ladder
while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry."]
What Happened? Tell us how the injury occurred.
[Examples: "When ladder slipped on wet floor, fell 20 feet"; "Developed soreness in wrist over time."]
What object, substance or motion directly injured you?
[Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank.]
What was the injury or illness?
[Tell us the part of the body that was affected and how it was affected. Examples: "strained back"; "chemical burn, right hand"; "carpal tunnel syndrome."]
Could this injury result in HIV infection?
Yes
No
[To be eligible for the HIV Benefit Plan, all work-related incidents that could result in HIV infection must be
called into the Disability Claims Unit (495-9054) and followed by authorized HIV blood testing within 5 calendar days of the incident.]
Information about the physician or other health care professional
Witness 1. Name:
Doctor/Hospital
Telephone #: (
)
Address
Witness 2. Name:
City
State
Zip
Telephone #: (
)
Signature of injured employee
Today's Date
/
/
TO BE COMPLETED BY THE SUPERVISOR TO WHOM THIS INJURY WAS REPORTED
Has employee lost more than 4 hours from work as a result of this alleged injury?
No
Yes
Unknown
If yes, submit current job description & list dates out
Has employee returned to work?
No
Yes, on
Date you first knew employee was allegedly injured at work?
/
/
If employee died, when did death occur? Date of death
/
/
Print Name
Telephone Number (
)
Signature
Today's Date
/
/
TO BE COMPLETED BY DEPARTMENT
33 Digit Payroll Code
TUB
ORG
OBJECT*
FUND
ACTIVITY
SUB-ACT
ROOT
*Object code required
Department Name and Unit
Address of Department (including city)
Employee's Job Title
Date of Hire
/
/
Union Code
Scheduled # of hours/week
Scheduled days off
Pay Rate:
$
/hour
Blended Rate? (check if yes)
Multiple Jobs? (check if yes)
Payroll Coordinator
Telephone Number (
)
This section completed by (print name)
Telephone Number (
)
Signature
Today's Date
/
/
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