Form 300a - Summary Of Work-Related Injuries And Illnesses
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2OSHA’s Form 300A
(Rev. 01/2004)
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
Total number of
Total number of
Industry description (
e.g., Manufacture of motor truck trailers
)
Total number of
Total number of
cases with days
deaths
cases with job
other recordable
_______________________________________________________
away from work
transfer or restriction
cases
Standard Industrial Classification (SIC), if known (
e.g., 3715
)
____ ____ ____ ____
__________________
__________________
__________________
__________________
OR
(G)
(H)
(I)
(J)
North American Industrial Classification (NAICS), if known (e.g., 336212)
____ ____ ____ ____ ____ ____
Number of Days
Total number of days away
Total number of days of job
(I
f you don’t have these figures, s
ee the
Employment information
Worksheet on the back of this page to estimate.)
from work
transfer or restriction
Annual average number of employees
______________
___________
___________
Total hours worked by all employees last year
______________
(K)
(L)
Injury and Illness Types
Sign here
Knowingly falsifying this document may result in a fine.
Total number of . . .
(M)
Injuries
______
Poisonings
______
(1)
(4)
I certify that I have examined this document and that to the best of my
Hearing loss
______
(5)
knowledge the entries are true, accurate, and complete.
Skin disorders
______
(2)
All other illnesses
______
(6)
___________________________________________________________
Respiratory conditions
______
(3)
Company executive
Title
___________________________________________________________
(
)
-
/ /
Phone
Date
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 Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW,
Washington, DC 20210. Do not send the completed forms to this office.
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