Form 301 - Injury And Illnesses Incident Report - Osha

Attention: This form contains information relating to

OSHA Form 301

employee health and must be used in a manner that protects

Year 20 __ __

®

Customized for the Veterinary Profession by Veterinary Practice Consultants

the confidentiality of employees to the extent possible while

U.S. Department of Labor

the information is being used for occupational safety & health

Injury and Illnesses Incident Report

Occupational Safety & Health Administration

purposes.

Form approved OMB no 1218-0176

This Injury & Illness Incident Report is one of the first forms you must fill out then a recordable work-related injury or illness has occurred. Together with the Log of Work-Related Injuries and Illnesses and the accompanying Summary , these forms help the employer and OSHA develop a picture of the

extent and severity of work-related incidents. 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 29CFR1904, OSHA’s recordkeeping rule, you must keep the form on file for 5 years following the year to which it pertains. If you need

additional copies of this form, you may photocopy and use as many as you need.

Information about the employee

Information about the case

Information about the investigation

(use the “NOTES” section on the reverse of this

form if additional space is needed to answer any question)

1) Full Name __________________________________________________

20) Was the incident the result of a violation of established safety

10) Case number from the log _____________

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policies?

No

Yes If yes, explain:

(transfer case number from the log after you record the case.)

2) Street ______________________________________________________

11) Date of Injury or illness _____/_____/_____

City___________________________ State ________ ZIP _____________

21) Has the employee received training to perform this procedure

safely?

12) Time employee began work ________________ AM/PM

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3) Date of birth _____/_____/_____

Yes

No If no, explain:

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13) Time of event _____________ AM/PM

Can not be determined

4) Date hired _____/_____/_____

22) Does the employee need additional training in this procedure?

14) What was the employee doing just before the incident occurred?

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5) Male

Female

No

Yes If yes, explain:

Describe the activity as well as the tools, equipment or materials the employee was using. Be

specific. (e.g., employee was preparing to clean the kennels with bleach.)

23) Are changes necessary in the operations or procedures of the

Information about the physician or other healthcare

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hospital that would prevent this type of accident in the future?

No

professional

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Yes

If yes, explain:

15) What happened?

Tell how the injury occurred. (e.g., When the employee opened the

6) Name of the professional _______________________________________

cage door the dog lunged and bit the employee.)

_____________________________________________________________

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24) Was this incident an animal bite or similar episode?

No

Yes

7) If treatment was given away from the worksite, where was it given?

16) What was the injury or illness?

Describe the part of the body that was affected and

If yes, Owner’s Name___________________________________________

how it was affected. (e.g., multiple puncture wounds to the right hand and forearm.)

Facility ______________________________________________________

Animal’s Name ________________________

Address ______________________________________________________

Date of last rabies vaccination _____/_____/_____

17) What object or substance directly harmed the employee?

Mark N/A if

City ____________________________ State _______ ZiIP _____________

this question is not applicable.

25) Was the animal quarantined and apparently healthy 10 days after

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the incident?

Yes

No If no, explain:

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8) Was employee treated in an emergency room? Yes

No

18) If the employee died, what date did death occur?

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_____/_____/_____

9) Was employee hospitalized overnight as an in-patient? Yes

No

26) Did the staff member require post-exposure rabies treatment?

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No

Yes

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 valid OMB control number. If you have any comments about these estimates or any other aspects ofof this data collection, contact: US Department of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Ave, NW, Washington, DC

20210. Do not send the completed forms to this office.