Attention: This form contains information relating

OSHA's Form 300 (Rev. 01/2004)

to employee health and must be used in a manner
that protects the confidentiality of employees to the Year
extent possible while the information is being used

Log of Work-Related Injuries and Illnesses for occupational safety and health purposes. U.S. Department of Labor
Occupational Safety and Health Administration

You must record information about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment Form approved OMB no. 1218-0176
beyond first aid. You must also record significant work-related injuries and 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 29 CFR 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must complete an
injury and illness incident report (OSHA Form 301) 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 OSHA office Establishment name
for help.
City State
Identify the person Describe the case Classify the case

Enter the number of

(A) (B) (C) (D) (E) (F)
CHECK ONLY ONE box for each case based on days the injured or ill Check the "injury" column or choose one type of
Case Employee's Name Job Title (e.g., Date of Where the event occurred (e.g. Describe injury or illness, parts of body affected, the most serious outcome for that case: worker was: illness:
No. Welder) injury or Loading dock north end) and object/substance that directly injured or made

All other illnesses

onset of person ill (e.g. Second degree burns on right (M)
illness forearm from acetylene torch) On job
Days away Away

Skin Disorder
transfer or

Hearing Loss
(mo./day) Death Remained at work
from work

Respiratory
From restriction

Poisoning
Condition
Work (days)
Job transfer Other record-

Injury
or restriction able cases (days)

(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6)

Page totals 0 0 0 0 0 0 0 0 0 0 0 0

Be sure to transfer these totals to the Summary page (Form 300A) before you post it.

Poisoning
Injury

Skin Disorder

Respiratory

Hearing Loss

All other illnesses

Condition
Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to
review the instruction, search and gather the data needed, and complete and review the collection of information. Persons
are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you
have any comments about these estimates or any aspects of this data collection, contact: US Department of Labor,
OSHA Office of Statistics, Room N-3644, 200 Constitution Ave, NW, Washington, DC 20210. Do not send the completed
forms to this office.
Page 1 of 1 (1) (2) (3) (4) (5) (6)
OSHA's Form 300A (Rev. 01/2004) Year

Summary of Work-Related Injuries and Illnesses U.S. Department of Labor

Occupational Safety and Health Administration

Form approved OMB no. 1218-0176

All establishments covered by Part 1904 must complete this Summary page, even if no injuries or
illnesses occurred 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. Then write the totals below, Establishment information
making sure you've added the entries from every page of the log. If you had no cases write "0."

Employees former employees, and their representatives have the right to review the OSHA Form 300 in its Your establishment name
entirety. They also have limited access to the OSHA Form 301 or its equivalent. See 29 CFR 1904.35, in
OSHA's Recordkeeping rule, for further details on the access provisions for these forms. Street

City State Zip

Number of Cases
Industry description (e.g., Manufacture of motor truck trailers)
Total number of Total number of Total number of cases Total number of
deaths cases with days with job transfer or other recordable
away from work restriction cases Standard Industrial Classification (SIC), if known (e.g., SIC 3715)
0 0 0 0
(G) (H) (I) (J) OR North American Industrial Classification (NAICS), if known (e.g., 336212)

Number of Days Employment information

Total number of Total number of days of

days away from job transfer or restriction Annual average number of employees
work
Total hours worked by all employees last
0 0 year
(K) (L)

Injury and Illness Types

Sign here

Total number of… Knowingly falsifying this document may result in a fine.
(M)
(1) Injury 0 (4) Poisoning 0
(2) Skin Disorder 0 (5) Hearing Loss 0
I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and
(3) Respiratory complete.
Condition 0 (6) All Other Illnesses 0

Company executive Title

Post this Summary page from February 1 to April 30 of the year following the year covered by the form Phone Date

Public reporting burden for this collection of information is estimated to average 58 minutes per response, including time to review the instruction, search and
gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it
displays a currently valid OMB control number. If you have any comments about these estimates or any aspects of this data collection, contact: US Department
of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Ave, NW, Washington, DC 20210. Do not send the completed forms to this office.
 Attention: This form contains information relating to
OSHA's Form 301 employee health and must be used in a manner that
protects the confidentiality of employees to the extent

Injuries and Illnesses Incident Report

possible while the information is being used for U.S. Department of Labor
occupational safety and health purposes.
Occupational Safety and Health Administration

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 Report 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 OSHA develop a picture of the extent 3) Date of birth 13) Time of event AM/PM Check if time cannot be determined
and severity of work-related incidents. *Please do not include any personally identifiable information (PII) pertaining to worker(s) involved in the incident (e.g., no names, phone
numbers, or SSNs) in the following fields.

Within 7 calendar days after you receive 4) Date hired *14) What was the employee doing just before the incident occurred? Describe the activity, as well
information that a recordable work-related injury or as the tools, equipment or material the employee was using. Be specific. Examples: "climbing a
illness has occurred, you must fill out this form or an 5) Male ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-
equivalent. Some state workers' compensation, entry."
Female
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.
*15) What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor,
According to Public Law 91-596 and 29 CFR 6) Name of physician or other health care professional worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement";
1904, OSHA's recordkeeping rule, you must keep "Worker developed soreness in wrist over time."
this form on file for 5 years following the year to
which it pertains
If you need additional copies of this form, you 7) If treatment was given away from the worksite, where was it given?
may photocopy and use as many as you need.
Facility *16) What was the injury or illness? Tell us the part of the body that was affected and how it was
affected. Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."
Street

City State Zip

8) Was employee treated in an emergency room?

Completed by Yes *17) What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine";
No "radial arm saw." If this question does not apply to the incident, leave it blank.
Title
9) Was employee hospitalized overnight as an in-patient?
Phone Date Yes
No 18) If the employee died, when did death occur? Date of death

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: US Department of Labor, OSHA Office of Statistics,
Room N-3644, 200 Constitution Ave, NW, Washington, DC 20210. Do not send the completed forms to this office.