Form Miosha-300a - Summary Of Work-Related Injuries And Illnesses - Michigan Department Of Licensing And Regulatory Affairs

Year

20

SUMMARY OF WORK-RELATED INJURIES AND ILLNESSES

Michigan Department of Licensing and Regulatory Affairs

Michigan Occupational Safety and Health Administration (MIOSHA)

Form Approved OMB No. 1218-0176

All establishments covered by Public Law of 1970 (P.O. 91-596) and Michigan Occupational Safety and Health Act 154, P.A. 1974, Part 11,

Michigan Administrative Rule for Recording and Reporting of Injuries and Illnesses, must complete this Summary page, even if no 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. You may be fined for failure to comply.

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."

Employees former employees, and their representatives have the right to review the MIOSHA Form 300 in its entirety. They also have limited

Your establishment name

access to the MIOSHA Form 301 or its equivalent. See Part 11, R408.22135 Rule 1135, in MIOSHA'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 cases

Total number of

deaths

cases with days

with job transfer or

other recordable

away from work

restriction

cases

Standard Industrial Classification (SIC), if known (e.g., SIC 3715)

(G)

(H)

(I)

(J)

OR

North American Industrial Classification (NAICS), if known (e.g., 336212)

Number of Days

Employment information

Total number of

Total number of days of

days away from

job transfer or restriction

Annual average number of employees

work

Total hours worked by all employees last

year

(K)

(L)

Injury and Illness Types

Sign here

Total number of…

Knowingly falsifying this document may result in a fine.

(M)

(1) Injury

(4) Poisonings

(2) Skin Disorder

(5) Hearing Loss

I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and

(3) Respiratory

complete.

Conditions

(6) All Other Illnesses

Company Executive

Title

Post this Summary page from February 1 to April 30 of the year following the year covered by the form

Phone

Date

Public reporting burden for this collection of information is estimated to average 50 minutes per response, including time to review the instruction, 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 aspects of this data collection, contact: Michigan Department of Licensing and Regulatory Affairs, MIOSHA,

TSD, 530 West Allegan Street, P.O. Box 30643, Lansing MI 48909-8143. (517) 284-7788. Do not send the completed forms to this office.

MIOSHA-300A (Rev. 12/16) Effective 01/01/2004