Osha Work-Related Injury And Illness Data Collection Form, 2011 Page 4
ADVERTISEMENT
1
2
3
4Did you have ANY occupational injuries or illnesses during 2011?
m Yes. Go to the next section, Summary of Work-Related Injuries and Illnesses, 2011.
m No. Go to Sign and return this form below.
Summary of Work-Related Injuries and Illnesses, 2011
Using your completed calendar year 2011 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A):
1. Copy the establishment summary information into the spaces below.
2. If you prefer, you may enclose a photocopy of your Summary of Work-Related Injuries and Illnesses (OSHA Form 300A).
3. If any total is zero on your OSHA Form 300A, write “0” in that total’s space below.
Number of Cases
Copy these totals
Total number
Total number
Total number
of cases with
of cases with
of other
from columns
Total number
days away
job transfer or
recordable
(G), (H), (I), and (J):
from work
of deaths
restriction
cases
(column H)
(column G)
(column I)
(column J)
Number of Days
Total number
Total number of
Copy these totals
of days away
days of job transfer
from columns (K)
from work
or restriction
(column K)
(column L)
and (L):
Injury and Illness Types
Total number of . . .
(1) Injuries
(4) Poisonings
from column (M)
(2) Skin disorders
(5) Hearing loss
(6) All other illnesses
(3) Respiratory conditions
Sign and return this form
Fill in the name, title, phone number, fax number, and email address of the person we should call with questions about this form.
Printed name
Phone, ex., 1234567890
Ext.
Fax, ex., 1234567890
Email, ex.,
06/21/2012
Title
Today’s date,
example: mm/dd/yyyy
Save Form
Print Form
Submit Form
4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Osha's Form 300 (rev. 01/2004) - Log Of Work-related Injuries And Illnesses With Instructions
Business
Osha Log - Forms For Recording Work-related Injuries And Illnesses - Us Department Of Labor
Business
Related Categories
Parent category: Business