SRALD Public Sector Guidelines of Occupational Injuries and Illnesses 2012 - Forms Only

              Oklahoma Department of Labor Statistical Research Unit 3017 N Stiles, Suite 100 Oklahoma City, OK 73105
OFFICIAL STATE BUSINESS
Recordkeeping Year 2012
THIS REPORT IS MANDATORY
Public Sector Guidelines of Occupational Injuries and Illnesses
Year 2012
FORMS ONLY
Year 2012
OK Form 300 -- Log of Work-Related Injuries & Illnesses Oklahoma Department of Labor 405-521-6100; 888-269-5353; www.labor.ok.gov
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.
Physical City
Location
Establishment
You must record information about every work-related death and about every work-related injury or illness that involves loss of conciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries that are diagnosed by a physician or licensed health care professional (PHLCP). 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 (2) single lines for a single case if you need to. You must complete an IInjury & Illness Incident Report (OK Form 301) for each injury or illness recorded on this form. If you’re not sure whether a case is recordable, call the Oklahoma Department of Labor for help at 1-888-269-5353.
Identify the person Describe the case Classify the case
(A)
Case no.
(B)
(C)
(D)
(E)
(F)
Employee's name
Job title (e. g., Welder)
Date of injury or onset of illness
Event location (e.g., Loading dock, north end)
Describe injury or illness, parts of body affected, and object/ substance that directly injured or made person ill (e.g., Second degree burns on right forearm from acetylene torch)
Using these four categories, "X" ONLY the most serious result for each case:
Enter number of days injured or ill worker was:
"X" injury column or choose one illness type:
Death
Days away from work
Remained at work
On job transfer or restriction
Other recordable cases
(G)
(H)
(I)
(J)
(K)
(L)
(1)
(2)
(3)
(4)
(5)
(6)
Away from work
On job transfer or restriction
(M)
Injury
Skin disorder
Respiratory condition
Poisoning
Page totals
Transfer these totals to the Summary page (Form 300A) before you post it.
(6)
(5)
(4)
(3)
(2)
(1)
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. If you have any comments about these estimates or any other aspects of this data collection, contact: Oklahoma Department of Labor, 3017 N Stiles, Suite 100, Oklahoma City, OK 73105; 1-888-269-5353.
Page
Notification & Recordkeeping Booklet
All other illnesses
Hearing loss

Page 4 of 11
Poisoning
Respiratory condition
Skin disorder
Injury
days
days
days
days
days
days
days
days
days
days
days
days
days
days
days
days
days
days
days
days
days
days
days
days
Hearing loss
All other illnesses
of
Section 1: Establishment Information
Instructions: All establishments covered by Part 1904 must complete the questions below, 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 total 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 OK Form 300 in its entirety. They also have limited access to the OK Form 301 or its equivalents. See 29 CFR Part 1904.35, in OSHA's recordkeeping rules, for further details on the access provisions of these forms.
Location Physical Address
Physical City
Mailing Zip Telephone
Mailing Address
Mailing City Mailing State
1. Annual average number of employees: 2. Total hours worked by all employees last year:
3. Check any conditions that might have affected your answers to questions 1 and 2 above during 2012:
Strike or lockout
Shutdown or layoff
Seasonal work
Natural disaster or adverse weather conditions
Shorter work schedules or fewer pay periods than usual
Longer work schedules or more pay periods than usual
Other reason:
Nothing unusual happened to affect our employment or hours figures.
4. Did you have ANY occupational injuries or illnesses during 2012?
Yes. Go to Section 2: OK Form 300A -- Summary of Work-Related Injuries and Illnesses, 2012.
No. Go to Section 3: Contact Information and Certification.
Page 10 of 11
Year 2012
OK Form 300A -- Summary of Work-Related Injuries & Illnesses Oklahoma Department of Labor 405-521-6100; 888-269-5353; www.labor.ok.gov
Mandatory


Establishment ID
Total number of deaths
(G)
(H)
(I)
(J)
Total number of other
recordable cases
Total number of cases with job
transfer or restriction
Total number of cases with
days away from work
Number of Cases
Number of Days
(L)
(K)
Total number of days away
from work
Total number of days of job
transfer or restriction
(M)
Total number of.....
Injury and Illness Types
(6) All other illnesses
(5) Hearing loss
(4) Poisonings
(3) Respiratory conditions
(2) Skin disorders
(1) Injuries
The total Number of Cases recorded in G + H + I + J must equal total Injury & Illnesses Types recorded in M (1 + 2 + 3 + 4 + 5 + 6).
I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate and complete.
Section 3: Contact Information and Certification
Name of Agency Executive / Representative Telephone Ext. Fax Number
Title E-Mail Today's Date (MM/DD/YYYY)
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. If you have any comments about these estimates or any other aspects of this data collection, contact: Oklahoma Department of Labor, 3017 N Stiles, Suite 100, Oklahoma City, OK 73105; 1-888-269-5353.
Post this Summary page from February 1st to April 30th, 2013.
Section 2: OK Form 300A -- Summary of Work-Related Injuries and Illnesses, 2011
(Knowingly falsifying this document may result in a fine.)
For each case in Column G or H complete the OK Form 301 -- Injury & Illness Report -- Case Information
Go to your completed OK Form 300. Copy the case information from that form into the spaces below. When submitting for the public sector survey, only include the OK Form 301 - Case Information page for incidents resulting in Cases with Days Away From Work (column H) or Death (column G).
Employee's name
(column B)
Job title
(column C)
Date of Injury
or onset
of Illness
(column D)
Number of
days away
from work
(column K)
Number of days
of job transfer
or restriction
(column L)
Tell us about the Employee
Office, professional, business, or management staff
Product assembly, product manufacture
Repair, installation or service of machines, equipment
Sales
Construction
Other:
Healthcare
Delivery or driving
Food service
Cleaning, Maintenance of building, grounds
Material handling (e.g. stocking, loading/unloading, moving, etc.)
Farming
1. Check the category which best describes the employee's regular type of job or work: (optional)
Tell us about the Incident
6. Time employee began work:
am
pm
7. Time of event:
OR
Event occurred:
before
during
after
work shift
8. What was the employee doing just before the incident
occurred? Describe the activity as well as the tools, equipment, or material the employee
was using. Be specific. Examples: "climbing a ladder while carrying roofing materials";
"spraying chlorine from hand sprayer"; "daily computer key-entry."
9. What happened? Tell us how the injury or illness occurred.
Examples: "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."
2. Employee's race or ethnic background: (optional-check one or more)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Not available
3. Employee's age: OR date of birth:
4. Employee's date hired:
OR check length of service at establishment when incident occurred:
Less than 3 months
From 3 to 11 months
From 1 to 5 years
More than 5 years
5. Employee's sex:
Male
Female
10. What was the injury or illness? Tell us the part of the body that was affected
and how it was affected; be more specific than "hurt," "pain," or "sore." Examples: "strained
back"; "chemical burn, hand"; "carpal tunnel syndrome."
11. What object or substance directly harmed the employee?
Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the
incident, leave it blank.
N
P
S
E
SS
OCC
MM-DD-YYYY
MM-DD-YYYY
12. Was the employee treated in an emergency room?
yes
no
13. Was employee hospitalized overnight as an in-patient?
14. If the employee died, record date of death:
MM-DD-YYYY
OK Form 301 -- Injury & Illness Report -- Case Information Oklahoma Department of Labor 405-521-6100; 888-269-5353; www.labor.ok.gov
Year 2012
Case
number
from Log
(column A)
Case Information
Page 11 of 11
yes
no
pm
am
Check if time cannot be determined
ID