Osha'S Form 301 - Injury And Illness Incident Report
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1OSHA’s Form 301
Attention: This form contains information relating to
employee health and must be used in a manner that
Injury and Illness
protects the confidentiality of employees to the
extent possible while the information is being used
Incident Report
for occupational safety and health purposes.
U.S. Department of Labor
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
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 29 CFR 1904, OSHA’s recordkeeping rule, you must keep this form on file for 5 years
following the year to which it pertains.
Information about the employee:
Information about the physician or other health care
professional:
6. ____________________________________________________
1. ________________________________________________________
Name of physician or other health care professional
Full Name
2. ________________________________________________________
7. If treatment was given away from the worksite, where was it given?
Street
________________________________________________
________________________________________________________
Facility
City, State, Zip
__________________________________________________________
3. Date of birth ____________________________
Address
4. Date hired
____________________________
8. Was employee treated in an emergency room?
5.
Male
Yes
No
9. Was employee hospitalized overnight as an in-patient?
Female
Yes
No
Information about the case:
10. Case number from the 300 Log ____________________________
12. Time employee began work _____________________________
11. Date of Injury or Illness
____________________________
13. Time of event
_____________________________
Check if time cannot be determined
14.
What was the employee doing just before the injury occurred?
Describe the activity, as well as the tools, equipment, or material the employee was using.
Be specific. Examples: “climbing a ladder while carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.”
15.
Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was sprayed with
What happened?
chlorine when gasket broke during replacement”; “Worker developed soreness in wrist over time.”
16.
Tell us the part of body that was affected and how it was affected; be more specific than “hurt,” “pain,” or “sore.”
What was the injury or illness?
Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.”
17.
Examples: “concrete floor”; “chlorine”; “radial arm saw.” Leave blank if not applicable.
What object or substance directly harmed the employee?
18.
If the employee died, when did death occur?
Date of death _____________________________________
Completed by _______________________________________________
Title ________________________________________________________
Phone __________________________________ Date ______________________
Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number. If you have any comments about this
estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Avenue, NW, Washington,
DC 20210 Do not send the completed forms to this office.
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