Osha 301 - Injury And Illness Incident Report Form printable pdf download

Osha 301 - Injury And Illness Incident Report Form

OSHA 301 – INJURY AND ILLNESS INCIDENT REPORT

The OSHA 301 Form - Injury and Illness Report is one of the first forms to be filled out when a recordable work-related injury or illness has

occurred.

Injured Persons Name: ______________________________________________________________________ Male

Female

Address:_________________________________________________________________________City:_______________________

State:______________________________________ Zip:_________________________ Phone #:____________________________

Date of Birth:_______________________________________ Date Hired:_________________________________________________

Job Titile:____________________________________________________________________________________________________

Signature:___________________________________________________________________________________________________

Hours per day worked__________ Days per week worked__________

Supervisor_______________________________________________________________Phone #:___________________________

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

Dr.Name:______________________________________________Facility:_____________________________________________

Address:_________________________________________________________________________City:_______________________

State:______________________________________ Zip:_________________________ Phone #:___________________________

Was the injured person treated in an emergency room?

Was the injured person hospitalized overnight as an in-patient?

Extent of treatment: (Circle One) None First Aid Medical Treatment

Date of injury or illness __________________ Time of event :________

Time injured person began work____________

Dates lost from work: __________________ to ________________

Dates on restricted duty: __________________ to _______________

Mark part of body injured on diagram provided.

Osha 301 - Injury And Illness Incident Report Form