Osha Log - Forms For Recording Work-Related Injuries And Illnesses - Us Department Of Labor Page 8
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12OSHA’s Form 300A
Year 20__ __
Summary of Work-Related Injuries and Illnesses
U.S. Department of Labor
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
All establishments covered by Part 1904 must complete this Summary page, even if no work-related injuries or illnesses occurred during the year. Remember to review the Log
to verify that the entries are complete and accurate before completing this summary.
Establishment information
Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you’ve added the entries from every page of the Log. If you
had no cases, write “0.”
Your establishment name
__________________________________________
Employees, former employees, and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access to the OSHA Form 301 or
its equivalent. See 29 CFR Part 1904.35, in OSHA’s recordkeeping rule, for further details on the access provisions for these forms.
Street
_________________________
_____________________
_______
City
____________________________
State ______
ZIP _________
Number of Cases
Industry description (
e.g., Manufacture of motor truck trailers
)
Total number of
Total number of
Total number of
Total number of
deaths
cases with days
cases with job
other recordable
_______________________________________________________
away from work
transfer or restriction
cases
Standard Industrial Classification (SIC), if known (
e.g., SIC 3715
)
____
____
____
____
__________________
__________________
__________________
__________________
(G)
(H)
(I)
(J)
Employment information
(I
f you don’t have these figures, s
ee the
Worksheet on the back of this page to estimate.)
Number of Days
Annual average number of employees
______________
Total number of days of
Total number of days
Total hours worked by all employees last year
______________
away from work
job transfer or restriction
Sign here
___________
___________
Knowingly falsifying this document may result in a fine.
(K)
(L)
Injury and Illness Types
I certify that I have examined this document and that to the best of my
knowledge the entries are true, accurate, and complete.
Total number of . . .
(M)
___________________________________________________________
Injuries
______
Poisonings
______
(1)
(4)
Company executive
Title
___________________________________________________________
All other illnesses
______
(5)
(
)
-
/
/
Phone
Date
Skin disorders
______
(2)
Respiratory conditions
______
(3)
Post this Summary page from February 1 to April 30 of the year following the year covered by the form.
Public reporting burden for this collection of information is estimated to average 50 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 about these estimates or any other aspects of this data collection, 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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