Osha Log - Forms For Recording Work-Related Injuries And Illnesses - Us Department Of Labor Page 7
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12Attention: This form contains information relating to
OSHA’s Form 300
employee health and must be used in a manner that
Year 20__ __
protects the confidentiality of employees to the extent
Log of Work-Related Injuries and Illnesses
possible while the information is being used for
U.S. Department of Labor
occupational safety and health purposes.
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer,
days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health
care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to
Establishment name ___________________________________________
use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this
form. If you’re not sure whether a case is recordable, call your local OSHA office for help.
City ________________________________ State ___________________
Identify the person
Describe the case
Classify the case
Enter the number of
(A)
(B)
(C)
(D)
(E)
(F)
Using these four categories, check ONLY
days the injured or
Check the “Injury” column or
ill worker was:
the most serious result for each case:
choose one type of illness:
Case
Employee’s name
Job title
Where the event occurred
Describe injury or illness, parts of body affected,
Date of injury
no.
(e.g
., Welder
)
(
e.g., Loading dock north end
)
or onset
and object/substance that directly injured
(M)
Days away
of illness
or made person ill
Death
On job
from work
Away
(
e.g., Second degree burns on right forearm from acetylene torch
)
Other record-
transfer
from
Job transfer
able cases
or restriction
work
or restriction
(G)
(H)
(I)
(J)
(1)
(2)
(3)
(4)
(5)
(K)
(L)
❑
❑
❑
❑
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ ____/___
_______
__________________
____
___________________
_______________________________ _____
days
days
month/day
❑
❑
❑
❑
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ ____/___
_______
_______________ _ ___
________________________________
__________________ _____
____
____
days
days
month/day
❑
❑
❑
❑
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ ____/___
_______
_______________ _ ___
______________________
____________________________ _____
____
____
days
days
month/day
❑
❑
❑
❑
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ ____/___
_______
_______________ _ ___
______________________
____________________________ _____
days
days
month/day
❑
❑
❑
❑
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ ____/___
_______
_______________ _ ___
___________________
_______________________________ _____
days
days
month/day
❑
❑
❑
❑
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ ____/___
_______
_______________ _ ___
______________________________
____________________ _____
____
____
days
days
month/day
❑
❑
❑
❑
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ ____/___
_______
_______________ _ ___
______________________________
____________________ _____
____
____
days
days
month/day
❑
❑
❑
❑
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ ____/___
_______
_______________ _ ___
______________________________
____________________ _____
days
days
month/day
❑
❑
❑
❑
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ ____/___
_______
_______________ _ ___
______________________________
____________________ _____
days
days
month/day
❑
❑
❑
❑
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ ____/___
_______
_______________ _ ___
___________________
_______________________________ _____
days
days
month/day
❑
❑
❑
❑
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ ____/___
_______
_______________ _ ___
______________________________
____________________ _____
____
____
days
days
month/day
❑
❑
❑
❑
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ ____/___
_______
_______________ _ ___
______________________________
____________________ _____
____
____
days
days
month/day
❑
❑
❑
❑
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ ____/___
_______
__________________
____
___________________
_______________________________ _____
days
days
month/day
____
____
____
____
____
____
Page totals
Be sure to transfer these totals to the Summary page (Form 300A) before you post it.
Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review
the instructions, search and gather the data needed, and complete and review the collection of information. Persons are not required
to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments
(1)
(2)
(3)
(4)
(5)
about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistics,
Page ____ of ____
Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.
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