Osha Form 301 - Injuries And Illnesses Incident Report

Attention: This form contains information relating to

OSHA's Form 301

employee health and must be used in a manner that

protects the confidentiality of employees to the extent

U.S. Department of Labor

possible while the information is being used for

Injuries and Illnesses Incident Report

occupational safety and health purposes.

Occupational Safety and Health Administration

Form approved OMB no. 1218-0176

Information about the employee

Information about the case

1)

Full Name

10)

Case number from the Log

(Transfer the case number from the Log after you record the case.)

This Injury and Illness Incident Repor t is one of the

first forms you must fill out when a recordable work-

2)

Street

11)

Date of injury or illness

related injury or illness has occurred. Together with

the Log of Work-Related injuries and Illnesses and

City

State

Zip

12)

Time employee began work

AM/PM

the accompanying Summary , these forms help the

employer and OSHA develop a picture of the extent

3)

Date of birth

13)

Time of event

AM/PM

Check if time cannot be determined

and severity of work-related incidents.

Within 7 calendar days after you receive

4)

Date hired

14)

What was the employee doing just before the incident occurred? Describe the activity, as well

information that a recordable work-related injury or

as the tools, equipment or material the employee was using. Be specific. Examples: "climbing a

5)

Male

ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-

illness has occurred, you must fill out this form or an

entry."

equivalent. Some state workers' compensation,

Female

insurance, or other reports may be acceptable

Information about the physician or other health care

substitutes. To be considered an equivalent form,

professional

any substitute must contain all the information

What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor,

asked for on this form.

15)

worker fell 20 feet"; "Worker was spayed with chlorine when gasket broke during replacement";

According to Public Law 91-596 and 29 CFR

6)

Name of physician or other health care professional

"Worker developed soreness in wrist over time."

1904, OSHA's recordkeeping rule, you must keep

this form on file for 5 years following the year to

which it pertains

If you need additional copies of this form, you

7)

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

may photocopy and use as many as you need.

Facility

16)

What was the injury or illness? Tell us the part of the body that was affected and how it was

affected; be more specific than "hurt", "pain", or "sore." Examples: "strained back"; "chemical burn,

Street

hand"; "carpal tunnel syndrome."

City

State

Zip

8)

Was employee treated in an emergency room?

Completed by

Yes

What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine";

17)

"radial arm saw." If this question does not apply to the incident, leave it blank.

No

Title

9)

Was employee hospitalized overnight as an in-patient?

Phone

Date

Yes

No

If the employee died, when did death occur? Date of death

18)

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 current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, 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.