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
Department of Consumer & Business
OSHA Form 300
that protects the confidentiality of employees to the extent possible while the information is being used
Services
for occupational safety and health purposes
Oregon Occupational Safety &
Log of Work-Related Injuries and Illnesses
Health Division (OR-OSHA)
You must record information about every work- related death and about every work-related injury or illness that involves loss of consciousness,
Establishment name:
restricted work activity, job transfer, days away from work, or medical treatment beyond first aid. You must also record significant work-related
illnesses that are diagnosed by a physician or licensed health-care professional. You must also record work-related injuries and illnesses that
meet any of the specific recording criteria listed in OAR 437-001-0700. Use more lines for each case if needed. You must complete an Injury and
City:
State:
Illness Incident Report (DCBS form 801) or equivalent form for each injury or illness recorded on this form. If you're not sure whether a case is
recordable, call your local OR-OSHA office for help.
Identify the person
Describe the case
Classify the case
Enter “1” in the “injury” column
Using these 4 categories,
Enter the number of
(A)
(B)
(C)
(D)
(E)
(F)
enter “1” in only the most
days the injured /
or choose one type of illness:*
Employee’s name
Case no.
Job title
Date of
Where the event
Describe Injury/Illness, parts of
serious result for each
worker was:
(M)
(e.g., “welder”)
injury or
occurred (e.g.,
body affected, and
case:*
“loading dock -
illness
object/substance that directly
Death
Days
Remained at
north end”
injured or made person ill (e.g.,
away
work
“second degree burns on right
from
forearm from acetylene torch”)
work
Job
Other
transf
record-
Away
On job
er or
able
from
transfer or
restric
cases
work
restriction
tion
(G)
(H)
(I)
(J)
(K)
(L)
(1)
(2)
(3)
(4)
(5)
(6)
0
0
0
0
0
0
0
0
0
0
days
days
0
0
0
0
0
0
0
0
0
0
days
days
0
0
0
0
0
0
0
0
0
0
days
days
0
0
0
0
0
0
0
0
0
0
days
days
0
0
0
0
0
0
0
0
0
0
days
days
0
0
0
0
0
0
0
0
0
0
days
days
0
0
0
0
0
0
0
0
0
0
days
days
0
0
0
0
0
0
0
0
0
0
days
days
0
0
0
0
0
0
0
0
0
0
days
days
0
0
0
0
0
0
0
0
0
0
days
days
0
0
0
0
0
0
0
0
0
0
days
days
0
0
0
0
0
0
0
0
0
0
days
days
0
0
0
0
0
0
0
0
0
0
days
days
Page Totals
0
0
0
0
0
0
0
0
0
0
0
0
days
days
Be sure to transfer these totals to the Summary (OSHA Form 300A) before you
post it
* Using “1” instead of an “x” allows the columns to total automatically.
Page
of
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(4)
(5)
(6)
440-3353A (12/03)
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