Osha Form 300 - Log Of Work-Related Injuries And Illnesses Page 2
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2Year 20
OSHA Form 300A
Department of Consumer & Business Services
Summary of Work-Related Injuries and Illnesses
Oregon Occupational Safety &
Health Division (OR-OSHA)
Form approved OMB no. 1218-0176
All establishments covered by OAR 437-001-0700 must complete this Summary, even if no work-related injuries or illnesses occurred
Establishment Information
during the year. Remember to review the Log to verify that the entries are complete and accurate before completing this summary.
Using the Log: count the individual entries you made for each category, write the totals below, make sure you've added the entries
Your establishment name
from every page of the Log. If you haven't had any cases, write "0".
Employees, former employees, and their representatives, have the right to review the OSHA Form 300 in its entirety. They also have
Street
limited access to the DCBS Form 801 or its equivalent. See OAR 437-001-0700(20)
City
State
ZIP
Number of Cases
Industry description (e.g., Manufacturer of motor truck trailers)
Total number of deaths
Total number of cases
Total number of
Total number of
with days away from work
cases with job
other recordable cases
transfer or restriction
Standard Industrial Classification (NAICS), if known
(e.g.,336212)
(G)
(H)
(I)
(J)
Employment Information (If you don’t have these figures, see
the worksheet on the back of this page to estimate.)
Number of Days
Annual average number of employees
Total number of days
Total number of days
away from work
of job transfer or restriction
Total hours worked by all employees last year
Sign here
(K)
(L)
Knowingly falsifying this document may result in a fine.
I certify that I have examined this document and that , to the best
Injury and Illness Types
of my knowledge, the entries are true, accurate, and complete.
Total number of…
(M)
Company Executive
Title
(1) Injuries
(4) Poisonings
Phone: (
)
Date:
/
/
(2) Skin disorders
(5) Hearing Loss
(3) Respiratory conditions
(6) All other illnesses
Keep this Summary posted from February 1 to April 30 of the year following the year covered by this form.
440-3353B (11/01)
(OR-OSHA/COM)
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Parent category: Business