Osha Injury And Illness Log And Summary
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1OSHA Injury and Illness Log and Summary
Public Law 91-596 and 29 CFR 1904 require you to:
Enter all recordable occupational injuries and illnesses. (See instructions on back.)
U.S. Department of Labor
This form is not an
Update and retain completed form for three years.
insurance form. Cases
Occupational Safety and Health Administration
Failure to complete, update and post can result in the issuance of citations and penalties.
listed below are not
necessarily eligible for
Form approved O.M.B. No. 1218-0000
Workers' Compensation
See O.M.B. disclosure statement on back.
Establishment Name
or other insurance.
Listing a case below
For calendar year _____
does not necessarily
Establishment Address
mean that the employer
Page ____ of ____
or worker was at fault or
Mailing Address if different
that an OSHA Standard
was violated.
Industry description and Standard Industrial Classification (SIC) if known ( e.g. Manufacture of motor truck trailers, SIC 3715)
CASE IDENTIFICATION
CASE DESCRIPTION
CASE CLASSIFICATION
(Check only one)
OTHER
A.
Employee's Name
F.
G.
H.
I.
E.
J.
B.
C.
D.
Death
Involving
Without Days Away
(e.g. Doe, Jane B.)
Description of injury or illness; part(s) of body
Regular
Employer
Case
Date of
Department and
Days Away
affected, and object/substance which directly
job title
Use
Num-
injury
location where
Restricted
injured or made employee ill
ber
or
event occurred
Work Activity
Other
(e.g. Second degree burns on right forearm
(e.g.
(e.g. 1,
illness
(e.g. loading
(X)
(X)
(# Days)
(X)
(X)
from acetylene torch)
Welder)
2,3...)
(m/d)
dock north end)
Year end totals
Employees, former employees, and their representatives have the right to
YEAR END SUMMARY
review all OSHA Injury and Illness Records, in their entirety, for this
Complete the year end
Annual average number of employees
establishment.
portion of this form,
even if there were no
Total hours worked by all employees
cases during the year.
Fold along line to the
I have examined this Log and Summary
right and post this
Title
Date
/
/
Phone
(
)
and certify its accuracy and completeness X
form from February 1
(Responsible Company Official)
to January 31 where
Knowingly falsifying this document can result in fine, imprisonment, or both.
Draft OSHA Form 300 (10/95)
employees can read
it.
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Parent category: Miscellaneous