Osha Form 301 - Injury And Illness Incident Report

Attention: This form contains inform ation relating to

OSHA Form 301

em ployee health and m ust be used in a m anner that protects

Year 20 __ __

®

Custom ized for the Veterinary Profession by SafetyVet

the confidentiality of em ployees to the extent possible while

U.S. Department of Labor

the inform ation is being used for occupational safety & health

Injury and Illnesses Incident Report

Occupational Safety & Health Administration

purposes.

Form approved OMB no 1218-0176

This Injury & Illness Incident Report is one of the first forms you must fill out then a recordable work-related injury or illness has occurred. Together with the Log of Work-Related Injuries and Illnesses and the accompanying Summary , these forms help the employer and OSHA develop a

picture of the extent and severity of work-related incidents. Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out this form or an equivalent. Some state workers’ compensation, insurance, or other reports

may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the information asked for on this form. According to Public Law 91-596 and 29CFR1904, OSHA’s recordkeeping rule, you must keep the form on file for 5 years following the year

to which it pertains. If you need additional copies of this form, you may photocopy and use as many as you need.

Information about the employee

Information about the case

Information about the investigation

(use the “NOTES” section on the reverse of

this form if additional space is needed to answer any question)

1) Full Name _________________________________________________

20) W as the incident the result of a violation of established safety

10) Case number from the log _____________

policies?

No

Yes If yes, explain:

(transfer case number from the log after you record the case.)

2) Street _____________________________________________________

11) Date of Injury or illness _____/_____/_____

City___________________________ State ________ ZIP _____________

21) Has the employee received training to perform this procedure safely?

Yes

No If no, explain:

12) Time employee began work ________________ AM/PM

3) Date of birth _____/_____/_____

13) Time of event _____________ AM /PM

Can not be determined

4) Date hired _____/_____/_____

22) Does the employee need additional training in this procedure?

No

Yes If yes, explain:

14) W hat was the employee doing just before the incident occurred?

5) Male

Female

Describe the activity as well as the tools, equipment or materials the employee was using. Be

specific. (e.g., employee was preparing to clean the kennels with bleach.)

23) Are changes necessary in the operations or procedures of the hospital

No

Yes

that would prevent this type of accident in the future?

If yes, explain:

Information about the physician or other healthcare

15) W hat happened?

Tell how the injury occurred. (e.g., When the employee opened

professional

the cage door the dog lunged and bit the employee.)

24) W as this incident an animal bite or similar episode?

No

Yes

6) Name of the professional ______________________________________

If yes, Owner’s Name___________________________________________

16) W hat was the injury or illness?

Describe the part of the body that was affected

_____________________________________________________________

and how it was affected. (e.g., multiple puncture wounds to the right hand and forearm.)

Animal’s Name ________________________

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

Date of last rabies vaccination _____/_____/_____

Facility ______________________________________________________

17) W hat object or substance directly harmed the employee?

Mark N/A if

25) W as the animal quarantined and apparently healthy 10 days after

this question is not applicable.

the incident?

Yes

No If no, explain:

Address ______________________________________________________

City __________________________ State _______ ZiIP ____________

26) Did the staff member require post-exposure rabies treatment?

18) If the employee died, what date did death occur? _____/_____/_____

No

Yes

8) W as employee treated in an emergency room? Yes

No

9) W as employee hospitalized overnight as an in-patient? Yes

No

Completed by: ___________________________________________________

Title: ___________________________

Phone: ______________________

Date: _____/_____/_____