Michigan Lara Injury And Illness Incident Report Form

INJURY AND ILLNESS INCIDENT REPORT

Michigan Department of Licensing and Regulatory Affairs

ATTENTION: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of

Michigan Occupational Safety and Health Administration (MIOSHA)

employees to the extent possible while the information is being used for occupational safety and health purposes.

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 MIOSHA develop a picture of the

3)

Date of birth

13)

Time of event

AM/PM

Check if time cannot be determined

extent and severity of work-related incidents.

4)

Date hired

14)

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

Within 7 calendar days after you receive

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

information that a recordable work-related injury or

5)

Male

Female

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

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,

Information about the physician or other health care

any substitute must contain all the information asked

professional

for on this form.

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

15)

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

According to Public Law of 1970 (P.L. 91-596)

6)

Name of physician or other health care professional

"Worker developed soreness in wrist over time."

and Michigan Occupational Safety and Health Act

154, P.A. 174, Part 11, Michigan Administrative Rule

for Recording and Reporting Of Injuries and

Illnesses, you must keep this form on file for 5 years

7)

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

following the year to which it pertains. You may be

fined for failure to comply.

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

Facility

16)

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

If you need additional copies of this form, you may

"carpal tunnel syndrome."

photocopy and use as many as you need.

Street

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: 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-301 (Rev. 08/15) Effective 01/01/2004