Osha 301 - Injury And Illness Incident Report Form (Page 2 of 3) in pdf

Osha 301 - Injury And Illness Incident Report Form Page 2

Information about the case

If the injured person died, Date of death: __________________

Location:____________________________________________________________

Witness:____________________________________________________________

What was the injured person doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or

material the

injured person was using. 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 the ladder slipped on wet floor, worker fell 20 feet";

"Worker was sprayed

with chlorine when gasket broke during replacement"; "Worker developed soreness of wrist over time."

What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than "hurt," "pain,"

or “sore”. Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."

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.

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 occupational safety and health purposes to the extent possible.

Osha 301 - Injury And Illness Incident Report Form Page 2