Osha Form 300 - Log Of Work-Related Injuries And Illnesses

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Attention: This form contains information relating
to employee health and must be used in a manner
OSHA's Form 300
(Rev. 01/2004)
Year
that protects the confidentiality of employees to the
extent possible while the information is being used
Log of Work-Related Injuries and Illnesses
U.S. Department of Labor
for occupational safety and health purposes.
Occupational Safety and Health Administration
You must record information about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment
Form approved OMB no. 1218-0176
beyond first aid. You must also record significant work-relate
Establishment name
City
State
Identify the person
Describe the case
Classify the case
Enter the number of
(A)
(B)
(C)
(D)
(E)
(F)
CHECK ONLY ONE box for each case based on
days the injured or ill
Check the "injury" column or choose one type of
Case
Employee's Name
Job Title (e.g.,
Date of
Where the event occurred (e.g.
Describe injury or illness, parts of body affected,
the most serious outcome for that case:
worker was:
illness:
No.
Welder)
injury or
Loading dock north end)
and object/substance that directly injured or made
(M)
onset of
person ill (e.g. Second degree burns on right
On job
illness
forearm from acetylene torch)
Days away
Away
Death
Remained at work
transfer or
(mo./day)
from work
From
restriction
Work
Job transfer
Other record-
(days)
(days)
or restriction
able cases
(G)
(H)
(I)
(J)
(K)
(L)
(1)
(2)
(3)
(4)
(5)
(6)
Page totals
0
0
0
0
0
0
0
0
0
0
0
0
Be sure to transfer these totals to the Summary page (Form 300A) before you post it.
Public reporting burden for this collection of information is estimated to average 14 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 no
Page
1 of 1
(1)
(2)
(3)
(4)
(5)
(6)

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