OSHA Forms for Recording Work-Related Injuries and Illnesses Form 300 1-1-04

              OSHA
Forms for Recording
Work-Related Injuries and Illnesses
What’s Inside…
In this package, you’ll find everything you need to complete
OSHA’s and the
for the next several years. On the following pages, you’ll find:
General instructions for filling out the forms in this package
and definitions of terms you should use when you classify
your cases as injuries or illnesses.
An example to guide you in filling
out the properly.
Several pages of the
(but you may make as many copies of
the as you need.) Notice that the
is separate from the
Removable pages
for easy posting at the end of the year.
Note that you post the only,
not the
A worksheet for
figuring the average number of employees who worked for
your establishment and the total number of hours worked.
A copy of the OSHA 301 to
provide details about the incident. You
may make as many copies as you need or
use an equivalent form.
Take a few minutes to review this package. If you have any
questions,
We’ll be happy to help you.
Log Summary of Work-Related Injuries and Illnesses
Log
Log
Log
Log Summary.
Summary
Summary
Log.
 
 
 
 
 
 
An Overview: Recording Work-Related Injuries and Illnesses
How to Fill Out the Log
Log of Work-Related Injuries and
Illnesses
Summary of Work-Related Injuries and
Illnesses
Worksheet to Help You Fill Out the Summary
OSHA’s 301: Injury and Illness Incident
Report
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or .
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visit us online at www.osha. gov call your local OSHA office
U.S. Department of Labor
Occupational Safety and Health Administration
Dear Employer:
This booklet includes the forms needed for maintaining
occupational injury and illness records for 2004. These new forms have
changed in several important ways from the 2003 recordkeeping forms.
In the ,
OSHA announced its decision to add an occupational hearing loss
column to OSHA’s Form 300, Log of Work-Related Injuries and
Illnesses. This forms package contains modified Forms 300 and
300A which incorporate the additional column M(5) Hearing Loss.
Employers required to complete the injury and illness forms must begin
to use these forms on January 1, 2004.
In response to public suggestions, OSHA also has made several
changes to the forms package to make the recordkeeping materials
clearer and easier to use:
• On Form 300, we’ve switched the positions of the day count
columns. The days “away from work” column now comes before
the days “on job transfer or restriction.”
• We’ve clarified the formulas for calculating incidence rates.
• We’ve added new recording criteria for occupational hearing loss
to the “Overview” section.
• On Form 300, we’ve made the column heading “Classify the
Case” more prominent to make it clear that employers should
mark only one selection among the four columns offered.
The Occupational Safety and Health Administration shares with you
the goal of preventing injuries and illnesses in our nation’s workplaces.
Accurate injury and illness records will help us achieve that goal.
December 17, 2002 Federal Register (67 FR 77165-77170)
Occupational Safety and Health Administration
U.S. Department of Labor
The
(Form 300) is used to classify work-related
injuries and illnesses and to note the extent
and severity of each case. When an incident
occurs, use the to record specific details
about what happened and how it happened.
The — a separate form (Form 300A)
— shows the totals for the year in each
category. At the end of the year, post the
in a visible location so that your
employees are aware of the injuries and
illnesses occurring in their workplace.
Employers must keep a for each
establishment or site. If you have more than
one establishment, you must keep a separate
and for each physical location that
is expected to be in operation for one year or
longer.
Note that your employees have the right to
review your injury and illness records. For
more information, see 29 Code of Federal
Regulations Part 1904.35,
Cases listed on the
are not necessarily eligible
for workers’ compensation or other insurance
benefits. Listing a case on the does not
mean that the employer or worker was at fault
or that an OSHA standard was violated.
Record those work-related injuries and
illnesses that result in:
death,
loss of consciousness,
days away from work,
restricted work activity or job transfer, or
medical treatment beyond first aid.
You must also record work-related injuries
and illnesses that are significant (as defined
below) or meet any of the additional criteria
listed below.
Log of Work-Related Injuries and Illnesses
Log
Summary
Summary
Log
Log Summary
Employee Involvement.
Log of Work-Related
Injuries and Illnesses
Log
When is an injury or illness considered
work-related?
Which work-related injuries and
illnesses should you record?
 
 
 
 
 
An injury or illness is considered
work-related if an event or exposure in the
work environment caused or contributed to the
condition or significantly aggravated a
preexisting condition. Work-relatedness is
presumed for injuries and illnesses resulting
from events or exposures occurring in the
workplace, unless an exception specifically
applies. See 29 CFR Part 1904.5(b)(2) for the
exceptions. The work environment includes
the establishment and other locations where
one or more employees are working or are
present as a condition of their employment.
See 29 CFR Part 1904.5(b)(1).
You must record any significant work-related
injury or illness that is diagnosed by a
physician or other licensed health care
professional. You must record any work-related
case involving cancer, chronic irreversible
disease, a fractured or cracked bone, or a
punctured eardrum. See 29 CFR 1904.7.
You must record the following conditions when
they are work-related:
any needlestick injury or cut from a sharp
object that is contaminated with another
person’s blood or other potentially
infectious material;
any case requiring an employee to be
medically removed under the requirements
of an OSHA health standard;
tuberculosis infection as evidenced by a
positive skin test or diagnosis by a physician
or other licensed health care professional
after exposure to a known case of active
tuberculosis.
an employee's hearing test (audiogram)
reveals 1) that the employee has
experienced a Standard Threshold Shift
(STS) in hearing in one or both ears
(averaged at 2000, 3000, and 4000 Hz) and
2) the employee's total hearing level is 25
decibels (dB) or more above audiometric
zero ( also averaged at 2000, 3000, and 4000
Hz) in the same ear(s) as the STS.
Medical treatment includes managing and
caring for a patient for the purpose of
combating disease or disorder. The following
are not considered medical treatments and are
NOT recordable:
visits to a doctor or health care professional
solely for observation or counseling;
What are the additional criteria?
What is medical treatment?
 
 
 
 
 
An Overview:
Recording Work-Related Injuries and Illnesses What do you need to do?
1. Within 7 calendar days after you
receive information about a case,
decide if the case is recordable under
the OSHA recordkeeping
requirements.
Determine whether the incident is a
new case or a recurrence of an existing
one.
.
dentify the employee involved unless
it is a privacy concern case as described
below.
dentify when and where the case
occurred.
Describe the case, as specifically as you
can.
Identify whether the case is an injury
or illness. If the case is an injury, check
the injury category. If the case is an
illness, check the appropriate illness
category.
2.
3.
4.
1.
2.
3.
4.
5.
Establish whether the case was work-related
If the case is recordable, decide which
form you will fill out as the injury and
illness incident report.
You may use
or an equivalent
form. Some state workers compensa-tion,
insurance, or other reports may
be acceptable substitutes, as long as
they provide the same information as
the OSHA 301.
I
I
Classify the seriousness of the case by
recording the
associated with the case, with column G
(Death) being the most serious and
column J (Other recordable cases)
being the least serious.
OSHA’s 301: Injury and
Illness Incident Report
How to work with the Log
most serious outcome
The Occupational Safety and Health (OSH) Act of 1970 requires certain employers to prepare and maintain records of work-related injuries and illnesses. Use these
definitions when you classify cases on the Log. OSHA’s recordkeeping regulation (see 29 CFR Part 1904) provides more information about the definitions below.
U.S. Department of Labor
Occupational Safety and Health Administration
 
 
 
 
 
 
 
 
diagnostic procedures, including
administering prescription medications that
are used solely for diagnostic purposes; and
any procedure that can be labeled first aid.
( )
You must consider the following types of
injuries or illnesses to be privacy concern cases:
an injury or illness to an intimate body part
or to the reproductive system,
an injury or illness resulting from a sexual
assault,
a mental illness,
a case of HIV infection, hepatitis, or
tuberculosis,
a needlestick injury or cut from a sharp
object that is contaminated with blood or
other potentially infectious material (see
29 CFR Part 1904.8 for definition), and
other illnesses, if the employee
independently and voluntarily requests that
his or her name not be entered on the log.
You must not enter the employee’s name on the
OSHA 300 for these cases. Instead, enter
“privacy case” in the space normally used for
the employee’s name. You must keep a separate,
confidential list of the case numbers and
employee names for the establishment’s privacy
concern cases so that you can update the cases
and provide information to the government if
asked to do so.
If you have a reasonable basis to believe
that information describing the privacy concern
case may be personally identifiable even though
the employee’s name has been omitted, you may
use discretion in describing the injury or illness
on both the OSHA 300 and 301 forms. You
must enter enough information to identify the
cause of the incident and the general severity of
the injury or illness, but you do not need to
include details of an intimate or private nature.
contusion, chipped
tooth,
See below for more information about first aid.
Log
Under what circumstances should you
NOT enter the employee’s name on the
OSHA Form 300?
Classifying injuries
An injury is any wound or damage to the body
resulting from an event in the work
environment.
Cut, puncture, laceration,
abrasion, fracture, bruise,
amputation, insect bite, electrocution, or
a thermal, chemical, electrical, or radiation
burn. Sprain and strain injuries to muscles,
joints, and connective tissues are classified as
injuries when they result from a slip, trip, fall or
other similar accidents.
Examples:
What is first aid?
If the incident required only the following types
of treatment, consider it first aid. Do NOT
record the case if it involves only:
using non-prescription medications at non-prescription
strength;
administering tetanus immunizations;
cleaning, flushing, or soaking wounds on the
skin surface;
using wound coverings, such as bandages,
BandAids™, gauze pads, etc., or using
SteriStrips™ or butterfly bandages.
using hot or cold therapy;
using any totally non-rigid means of support,
such as elastic bandages, wraps, non-rigid
back belts, etc.;
using temporary immobilization devices
while transporting an accident victim
(splints, slings, neck collars, or back boards).
drilling a fingernail or toenail to relieve
pressure, or draining fluids from blisters;
using eye patches;
using simple irrigation or a cotton swab to
remove foreign bodies not embedded in or
adhered to the eye;
using irrigation, tweezers, cotton swab or
other simple means to remove splinters or
foreign material from areas other than the
eye;
using finger guards;
using massages;
drinking fluids to relieve heat stress
Restricted work activity occurs when, as the
result of a work-related injury or illness, an
employer or health care professional keeps, or
recommends keeping, an employee from doing
the routine functions of his or her job or from
working the full workday that the employee
would have been scheduled to work before the
injury or illness occurred.
If the outcome or extent of an injury or illness
changes after you have recorded the case,
simply draw a line through the original entry or,
if you wish, delete or white-out the original
entry. Then write the new entry where it
belongs. Remember, you need to record the
most serious outcome for each case.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
How do you decide if the case involved
restricted work?
How do you count the number of days
of restricted work activity or the
number of days away from work?
What if the outcome changes after you
record the case?
Count the number of calendar days the
employee was on restricted work activity or was
away from work as a result of the recordable
injury or illness. Do not count the day on which
the injury or illness occurred in this number.
Begin counting days from the day the
incident occurs. If a single injury or illness
involved both days away from work and days of
restricted work activity, enter the total number
of days for each. You may stop counting days of
restricted work activity or days away from work
once the total of either or the combination of
both reaches 180 days.
after
U.S. Department of Labor
Occupational Safety and Health Administration
Classifying illnesses
Skin diseases or disorders
Respiratory conditions
Hearing Loss
All other illnesses
Skin diseases or disorders are illnesses involving
the worker’s skin that are caused by work
exposure to chemicals, plants, or other
substances.
Contact dermatitis, eczema, or
rash caused by primary irritants and sensitizers
or poisonous plants; oil acne; friction blisters,
chrome ulcers; inflammation of the skin.
Respiratory conditions are illnesses associated
with breathing hazardous biological agents,
chemicals, dust, gases, vapors, or fumes at work.
Silicosis, asbestosis, pneumonitis,
pharyngitis, rhinitis or acute congestion;
farmer’s lung, beryllium disease, tuberculosis,
occupational asthma, reactive airways
dysfunction syndrome (RADS), chronic
obstructive pulmonary disease (COPD),
hypersensitivity pneumonitis, toxic inhalation
injury, such as metal fume fever, chronic
obstructive bronchitis, and other
pneumoconioses.
Noise-induced hearing loss is defined for
recordkeeping purposes as a change in hearing
threshold relative to the baseline audiogram of
an average of 10 dB or more in either ear at
2000, 3000 and 4000 hertz
All other occupational illnesses.
Heatstroke, sunstroke, heat
exhaustion, heat stress and other effects of
environmental heat; freezing, frostbite, and
other effects of exposure to low temperatures;
decompression sickness; effects of ionizing
radiation (isotopes, x-rays, radium); effects of
nonionizing radiation (welding flash, ultra-violet
rays, lasers); anthrax; bloodborne pathogenic
diseases, such as AIDS, HIV, hepatitis B or
hepatitis C; brucellosis; malignant or
Examples:
Examples:
Examples:
Poisoning
Poisoning includes disorders evidenced by
abnormal concentrations of toxic substances in
blood, other tissues, other bodily fluids, or the
breath that are caused by the ingestion or
absorption of toxic substances into the body.
Poisoning by lead, mercury,
cadmium, arsenic, or other metals; poisoning by
carbon monoxide, hydrogen sulfide, or other
gases; poisoning by benzene, benzol, carbon
tetrachloride, or other organic solvents;
poisoning by insecticide sprays, such as
parathion or lead arsenate; poisoning by other
chemicals, such as formaldehyde.
Examples:
benign
tumors; histoplasmosis; coccidioidomycosis.
, and the employee’s
total hearing level is 25 decibels (dB) or more
above audiometric zero (also averaged at 2000,
3000, and 4000 hertz) in the same ear(s).
When must you post the Summary?
How long must you keep the Log
and Summary on file?
Do you have to send these forms to
OSHA at the end of the year?
How can we help you?
You must post the only not the
by February 1 of the year following the
year covered by the form and keep it posted
until April 30 of that year.
You must keep the and for
5 years following the year to which they
pertain.
No. You do not have to send the completed
forms to OSHA unless specifically asked to
do so.
If you have a question about how to fill out
the ,
or
Summary —
Log —
Log Summary
Log
 
 
visit us online at www.osha.gov
call your local OSHA office.
U.S. Department of Labor
Occupational Safety and Health Administration
What is an incidence rate?
How do you calculate an incidence
rate?
What can I compare my incidence
rate to?
An incidence rate is the number of recordable
injuries and illnesses occurring among a given
number of full-time workers (usually 100 full-time
workers) over a given period of time
(usually one year). To evaluate your firm’s
injury and illness experience over time or to
compare your firm’s experience with that of
your industry as a whole, you need to compute
your incidence rate. Because a specific number
of workers and a specific period of time are
involved, these rates can help you identify
problems in your workplace and/or progress
you may have made in preventing work-related
injuries and illnesses.
You can compute an occupational injury and
illness incidence rate for all recordable cases or
for cases that involved days away from work for
your firm quickly and easily. The formula
requires that you follow instructions in
paragraph (a) below for the total recordable
cases or those in paragraph (b) for cases that
involved days away from work, for both
rates the instructions in paragraph (c).
(a)
count the number of line entries on your
OSHA Form 300, or refer to the OSHA Form
300A and sum the entries for columns (G), (H),
(I), and (J).
(b)
count
the number of line entries on your OSHA
Form 300 that received a check mark in
column (H), or refer to the entry for column
(H) on the OSHA Form 300A.
(c)
. Refer to OSHA Form
300A and optional worksheet to calculate this
number.
You can compute the incidence rate for all
recordable cases of injuries and illnesses using
the following formula:
(The 200,000 figure in the formula represents
the number of hours 100 employees working
40 hours per week, 50 weeks per year would
work, and provides the standard base for
calculating incidence rates.)
You can compute the incidence rate for
recordable cases involving days away from
work, days of restricted work activity or job
transfer (DART) using the following formula:
You can use the same formula to calculate
incidence rates for other variables such as cases
involving restricted work activity (column (I)
on Form 300A), cases involving skin disorders
(column (M-2) on Form 300A), etc. Just
substitute the appropriate total for these cases,
from Form 300A, into the formula in place of
the total number of injuries and illnesses.
The Bureau of Labor Statistics (BLS) conducts
a survey of occupational injuries and illnesses
each year and publishes incidence rate data by
various classifications (e.g., by industry, by
employer size, etc.). You can obtain these
published data at www.bls.gov/iif or by calling a
BLS Regional Office.
and
To find out the total number of recordable
injuries and illnesses that occurred during the year,
To find out the number of injuries and
illnesses that involved days away from work,
The number of hours all employees actually
worked during the year
Total number of injuries and illnesses 200,000 ÷
Number of hours worked by all employees = Total
recordable case rate
(Number of entries in column H + Number of
entries in column I) 200,000 ÷ Number of hours
worked by all employees = DART incidence rate
X
X
Optional
Calculating Injury and Illness Incidence Rates
Worksheet
U.S. Department of Labor
Occupational Safety and Health Administration
Number of entries in
Column H + Column I
DART incidence
rate
Number of
hours worked
by all employees
Total number of
injuries and illnesses
X 200,000 =
Total recordable
case rate
Number of
hours worked
by all employees
X 200,000 =
The is
used to classify work-related injuries and
illnesses and to note the extent and severity
of each case. When an incident occurs, use
the to record specific details about what
happened and how it happened.
We have given you several copies of the
in this package. If you need more than
we provided, you may photocopy and use as
many as you need.
The — a separate form —
shows the work-related injury and illness
totals for the year in each category. At the
end of the year, count the number of
incidents in each category and transfer the
totals from the to the Then
post the in a visible location so that
your employees are aware of injuries and
illnesses occurring in their workplace.
Log of Work-Related Injuries and Illnesses
Log
Log
Summary
Log Summary.
Summary
If your company has more than one
establishment or site, you must keep
separate records for each physical location
that is expected to remain in operation for
one year or longer.
You don’t post the Log. You post only
the Summary at the end of the year.
How to Fill Out the Log
U.S. Department of Labor
Occupational Safety and Health Administration
Revise the log if the injury or illness
progresses and the outcome is more
serious than you originally recorded for
the case. Cross out, erase, or white-out
the original entry.
Be as specific as possible. You
can use two lines if you need
more room. Note whether the
case involves an
injury or an illness.
Choose ONLY ONE of these
categories. Classify the case
by recording the most
serious outcome of the case,
with column G (Death) being
the most serious and column
J (Other recordable cases)
being the least serious.
}
Check the “Injury” column or
choose one type of illness:
R
Describe injury or illness, parts of body affected,
and object/substance that directly injured
or made person ill
(A) (B) (C) (D) (E) (F)
(G) (H) (I) (J) (K) (L)
(1) (2) (3) (4) (5) (6) Skin disorders
Respiratory
conditions
Poisoning
Hearing loss
All other
illnesses
Injury
You must record information about every work-related death and 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 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 Part 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 for help.
(M)
Attention: This form contains information relating to
employee health and must be used in a manner that
protects the confidentiality of employees to the extent
possible while the information is being used for
occupational safety and health purposes.
XYZ Company
Anywhere MA
Form approved OMB no. 1218-0176
Death
Days away
from work
Job transfer
or restriction
Remained at Work
Other record-able
cases
Away
from
work
On job
transfer or
restriction
Enter the number of
days the injured or
ill worker was:
CHECK ONLY ONE box for each case
based on the most serious outcome for
that case:
(Rev. 01/2004)
U.S. Department of Labor
Occupational Safety and Health Administration
OSHA’s Form 300 (Rev. 01/2004) Year 20__ __
Log of Work-Related Injuries and Illnesses
You must record information about every work-related death and 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 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 Part 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 for help.
Form approved OMB no. 1218-0176
Page ____ of ____
Skin disorder
Respiratory
condition
Poisoning
Hearing loss
All other
illnesses
Be sure to transfer these totals to the Summary page (Form 300A) before you post it.
Page totals
Establishment name ___________________________________________
City ________________________________ State ___________________
Injury
Enter the number of
days the injured or
ill worker was:
Check the “Injury” column or
choose one type of illness:
month/day
month/day
month/day
month/day
month/day
month/day
month/day
month/day
month/day
month/day
month/day
month/day
month/day
Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review
the instructions, 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 other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical
Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.
(A) (B) (C) (D) (E) (F)
(M)
(G) (H) (I) (J) (K) (L)
Death
Days away
from work
On job
transfer or
restriction
Away
from
work
Attention: This form contains information relating to
employee health and must be used in a manner that
protects the confidentiality of employees to the extent
possible while the information is being used for
occupational safety and health purposes.
CHECK ONLY ONE box for each case
based on the most serious outcome for
that case:
Job transfer
or restriction
Other record-able
cases
Remained at Work
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(1) (2) (3) (4) (5) (6)
(1) (2) (3) (4) (5) (6)
Skin disorder
Respiratory
condition
Poisoning
Hearing loss
All other
illnesses
Injury
Identify the person Describe the case Classify the case
Case Employee’s name Job title Date of injury Where the event occurred Describe injury or illness, parts of body affected,
of illness or made person ill (
no. or onset and object/substance that directly injured
e.g., Second degree burns on
e.g., Welder e.g., Loading dock north end
right forearm from acetylene torch
( ) ( )
)
_____ ________________________ ____________ __________/______ __________________ ___________________________________________________ ____ ____
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days days
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U.S. Department of Labor
Occupational Safety and Health Administration
OSHA’s Form 300A (Rev. 01/2004) Year 20__ __
Summary of Work-Related Injuries and Illnesses
Form approved OMB no. 1218-0176
Total number of
deaths
__________________
Total number of
cases with days
away from work
__________________
Number of Cases
Total number of days away
from work
___________
Total number of days of job
transfer or restriction
___________
Number of Days
Post this Summary page from February 1 to April 30 of the year following the year covered by the form.
All establishments covered by Part 1904 must complete this Summary page, even if no work-related 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, 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 entirety. They also have limited access to the OSHA Form 301 or
its equivalent. See 29 CFR Part 1904.35, in OSHA’s recordkeeping rule, for further details on the access provisions for these forms.
Establishment information
Employment information
Your establishment name __________________________________________
Street _________________________ _______
City ____________________________ State ______ ZIP _________
Industry description ( )
_______________________________________________________
Standard Industrial Classification (SIC), if known ( )
____ ____ ____ ____
North American Industrial Classification (NAICS), if known (e.g., 336212)
e.g., Manufacture of motor truck trailers
e.g., 3715
(I ee the
Worksheet on the back of this page to estimate.)
_____________________
OR
____ ____ ____ ____ ____ ____
Annual average number of employees ______________
Total hours worked by all employees last year ______________
f you don’t have these figures, s
Sign here
Knowingly falsifying this document may result in a fine.
I certify that I have examined this document and that to the best of my
knowledge the entries are true, accurate, and complete.
___________________________________________________________
___________________________________________________________
Company executive Title
Phone Date
( ) - / /
Public reporting burden for this collection of information is estimated to average 50 minutes per response, including time to review the instructions, 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 other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW,
Washington, DC 20210. Do not send the completed forms to this office.
Total number of . . .
Skin disorders ______
Respiratory conditions ______
Injuries ______
Injury and Illness Types
Poisonings ______
Hearing loss
All other illnesses ______
______
(G) (H) (I) (J)
(K) (L)
(M)
(1)
(2)
(3)
(4)
(5)
(6)
Total number of
cases with job
transfer or restriction
__________________
Total number of
other recordable
cases
__________________
At the end of the year, OSHA requires you to enter the average number of employees and the total hours worked by your employees on the summary. If you don’t have these figures, you can use the
information on this page to estimate the numbers you will need to enter on the Summary page at the end of the year.
For example, Acme Construction figured its average employment this way:
For pay period… Acme paid this number of employees…
1 10
2 0
3 15
4 30
5 40
24 20
25 15
26 +
830
▼ ▼
10
How to figure the average number of employees
who worked for your establishment during the
year:
 
 
 
 
Add
Count
Divide
Round the answer
the total number of employees your
establishment paid in all pay periods during the
year. Include all employees: full-time, part-time,
temporary, seasonal, salaried, and hourly.
the number of pay periods your
establishment had during the year. Be sure to
include any pay periods when you had no
employees.
the number of employees by the number of
pay periods.
to the next highest whole
number. Write the rounded number in the blank
marked Annual average number of employees.
The number of employees
paid in all pay periods =
The number of pay
periods during the year =
=
The number rounded =
 
 
 
 
How to figure the total hours worked by all employees:
Include hours worked by salaried, hourly, part-time and seasonal workers, as
well as hours worked by other workers subject to day to day supervision by
your establishment (e.g., temporary help services workers).
Do not include vacation, sick leave, holidays, or any other non-work time,
even if employees were paid for it. If your establishment keeps records of only
the hours paid or if you have employees who are not paid by the hour, please
estimate the hours that the employees actually worked.
If this number isn’t available, you can use this optional worksheet to
estimate it.
Optional
Worksheet to Help You Fill Out the Summary
U.S. Department of Labor
Occupational Safety and Health Administration
Find
Multiply
Add
Round
the number of full-time employees in your
establishment for the year.
by the number of work hours for a full-time
employee in a year.
This is the number of full-time hours worked.
the number of any overtime hours as well as the
hours worked by other employees (part-time,
temporary, seasonal)
the answer to the next highest whole number.
Write the rounded number in the blank marked Total
hours worked by all employees last year.
x
+
Optional Worksheet
Number of employees paid = 830
Number of pay periods = 26
= 31.92
26
31.92 rounds to 32
32 is the annual average number of employees
830
Information about the employee
Information about the physician or other health care
professional
Full name
Street
City State ZIP
Date of birth
Date hired
Male
Female
Name of physician or other health care professional
If treatment was given away from the worksite, where was it given?
Facility
Street
City State ZIP
Was employee treated in an emergency room?
Yes
No
Was employee hospitalized overnight as an in-patient?
Yes
No
_____________________________________________________________
________________________________________________________________
______________________________________ _________ ___________
______ / _____ / ______
______ / _____ / ______
__________________________
________________________________________________________________________
_________________________________________________________________
_______________________________________________________________
______________________________________ _________ ___________
 
 
 
 
 
 
U.S. Department of Labor
Occupational Safety and Health Administration
OSHA’s Form 301
Injury and Illness Incident Report
Form approved OMB no. 1218-0176
This is one of the
first forms you must fill out when a recordable work-related
injury or illness has occurred. Together with
the and the
accompanying these forms help the
employer and OSHA develop a picture of the extent
and severity of work-related incidents.
Within 7 calendar days after you receive
information that a recordable work-related injury or
illness has occurred, you must fill out this form or an
equivalent. Some state workers’ compensation,
insurance, or other reports may be acceptable
substitutes. To be considered an equivalent form,
any substitute must contain all the information
asked for on this form.
According to Public Law 91-596 and 29 CFR
1904, OSHA’s recordkeeping rule, you must keep
this form on file for 5 years following the year to
which it pertains.
If you need additional copies of this form, you
may photocopy and use as many as you need.
Injury and Illness Incident Report
Log of Work-Related Injuries and Illnesses
Summary,
Information about the case
Case number from the
Date of injury or illness
Time employee began work
Time of event Check if time cannot be determined
Date of death
Log _____________________ (Transfer the case number from the Log after you record the case.)
______ / _____ / ______
____________________
____________________
______ / _____ / ______
AM / PM
AM / PM  
What was the employee doing just before the incident occurred?
What happened?
What was the injury or illness?
What object or substance directly harmed the employee?
If the employee died, when did death occur?
Describe the activity, as well as the
tools, equipment, or material the employee was using. Be specific. “climbing a ladder while
carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.”
Tell us how the injury occurred. “When ladder slipped on wet floor, worker
fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker
developed soreness in wrist over time.”
Tell us the part of the body that was affected and how it was affected; be
more specific than “hurt,” “pain,” or sore.” “strained back”; “chemical burn, hand”; “carpal
tunnel syndrome.”
“concrete floor”; “chlorine”;
“radial arm saw.”
Examples:
Examples:
Examples:
Examples:
If this question does not apply to the incident, leave it blank.
Completed by
Title
Phone Date
_______________________________________________________
_________________________________________________________________
(________)_________--_____________ _____/ _ _____ / _____
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 Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW,
Washington, DC 20210. Do not send the completed forms to this office.
10)
11)
12)
13)
14)
15)
16)
17)
18)
1)
2)
3)
5)
6)
7)
8)
9)
4)
Attention: This form contains information relating to
employee health and must be used in a manner that
protects the confidentiality of employees to the extent
possible while the information is being used for
occupational safety and health purposes.
If you need help deciding whether a case is recordable, or if you have questions about the information in this package, feel free to
contact us. We’ll gladly answer any questions you have.
If You Need Help…
 
 
 
Visit us online at www.osha.gov
Call your OSHA Regional office
and ask for the recordkeeping
coordinator
or
Call your State Plan office
Federal Jurisdiction State Plan States
Region 1 - 617 / 565-9860
Region 2 - 212 / 337-2378
Region 3 - 215 / 861-4900
Region 4 - 404 / 562-2300
Region 5 - 312 / 353-2220
Region 6 - 214 / 767-4731
Region 7 - 816 / 426-5861
Region 8 - 303 / 844-1600
Region 9 - 415 / 975-4310
Region 10 - 206 / 553-5930
Connecticut; Massachusetts; Maine; New
Hampshire; Rhode Island
New York; New Jersey
DC; Delaware; Pennsylvania; West Virginia
Alabama; Florida; Georgia; Mississippi
Illinois; Ohio; Wisconsin
Arkansas; Louisiana; Oklahoma; Texas
Kansas; Missouri; Nebraska
Colorado; Montana; North Dakota; South
Dakota
Idaho
Alaska - 907 / 269-4957
Arizona - 602 / 542-5795
California - 415 / 703-5100
*Connecticut - 860 / 566-4380
Hawaii - 808 / 586-9100
Indiana - 317 / 232-2688
Iowa - 515 / 281-3661
Kentucky - 502 / 564-3070
Maryland - 410 / 767-2371
Michigan - 517 / 322-1848
Minnesota - 651 / 284-5050
Nevada - 702 / 486-9020
*New Jersey - 609 / 984-1389
New Mexico - 505 / 827-4230
*New York - 518 / 457-2574
North Carolina - 919 / 807-2875
Oregon - 503 / 378-3272
Puerto Rico - 787 / 754-2172
South Carolina - 803 / 734-9669
Tennessee - 615 / 741-2793
Utah - 801 / 530-6901
Vermont - 802 / 828-2765
Virginia - 804 / 786-6613
Virgin Islands - 340 / 772-1315
Washington - 360 / 902-5601
Wyoming - 307 / 777-7786
*Public Sector only
U.S. Department of Labor
Occupational Safety and Health Administration
Have questions?
If you need help in filling out the or or if you
have questions about whether a case is recordable, contact
us. We’ll be happy to help you. You can:
Visit us online at:
Call your regional or state plan office. You’ll find the
phone number listed inside this cover.
Log Summary,
 
 
www.osha.gov
U.S. Department of Labor
Occupational Safety and Health Administration