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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 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 or .

visit us online at www.osha. gov call your local OSHA office

U .S

D e p a rt m n t o f

L b r O c u ti l S fe ty d

H lt h A in is tr

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

LOGISTIC SUPPORT SERVICES

OSHA

Forms for Recording Work-Related Injuries and Illnesses

Attachment 4

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

Employee Involvement.

Log of Work-Related

Injuries and Illnesses

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.

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.

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

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

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.

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 visit us online at www.osha.gov call your local OSHA office.

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

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 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

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)

Sk de rs es pi ra to ry co nd iti on s

Po g ea ri ng lo ss ll ot he ill ne

In ju

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)

OSHA’s Form 300 (Rev. 01/2004) Year 20__ __

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.

Page ____ of ____

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

Page totals

Establishment name ___________________________________________

City ________________________________ State ___________________

Enter the number of days the injured or ill worker was:

Check the “Injury” column or choose one type of illness:

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)

(K) (L)(G) (H) (I) (J)

Death Days away

On job transfer or restriction

Away from work protects the confidentiality of employees to the extent

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

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 days days

OSHA’s Form 300A (Rev. 01/2004) Year 20__ __

Summary of Work-Related Injuries and Illnesses deaths cases with days away from work

Number of Cases

Total number of days away

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 58 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)

(1)

(2)

(3)

(4)

(5)

(6) cases with job transfer or restriction 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 +

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 n 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

31.92 rounds to 32

32 is the annual average number of employees

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

OSHA’s Form 301 Injury and Illness Incident Report

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

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.”

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) protects the confidentiality of employees to the extent

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… t Visit us online at www.osha.gov t Call your OSHA Regional office and ask for the recordkeeping coordinator t Call your State Plan office

Federal Jurisdiction State Plan States

Alaska - 907 / 269-4957Region 1 - 617 / 565-9860 Connecticut; Massachusetts; Maine; New Hampshire; Rhode Island Arizona - 602 / 542-5795

Region 2 - 212 / 337-2378 California - 415 / 703-5100 New York; New Jersey

*Connecticut - 860 / 566-4380

Region 3 - 215 / 861-4900 DC; Delaware; Pennsylvania; West Virginia Hawaii - 808 / 586-9100

Indiana - 317 / 232-2688Region 4 - 404 / 562-2300 Alabama; Florida; Georgia; Mississippi

Iowa - 515 / 281-3661

Region 5 - 312 / 353-2220 Kentucky - 502 / 564-3070Illinois; Ohio; Wisconsin

Maryland - 410 / 527-4465Region 6 - 214 / 767-4731 Arkansas; Louisiana; Oklahoma; Texas

Michigan - 517 / 322-1848

Region 7 - 816 / 426-5861 Minnesota - 651 / 284-5050Kansas; Missouri; Nebraska

Nevada - 702 / 486-9020 Region 8 - 303 / 844-1600 Colorado; Montana; North Dakota; South

*New Jersey - 609 / 984-1389Dakota

New Mexico - 505 / 827-4230Region 9 - 415 / 975-4310

*New York - 518 / 457-2574 Region 10 - 206 / 553-5930 Idaho

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 / 902-5554

Wyoming - 307 / 777-7786

*Public Sector only

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

LOGISTICS SUPPORT SERVICES

ATTACHMENT 5

ACTIVE SHOOTER THREAT TRAINING LIST

COMPANY NAME: ___________________________________

EMPLOYEE NAME

DATE EMPLOYEE

REPORTS ON CENTER

DATE OF

TRAINING

DHS Form 11000-6 (8/04) Page 1 of 3

Attachment 7 LOGISTICS SUPPORT SERVICES

DEPARTMENT OF HOMELAND SECURITY

NON-DISCLOSURE AGREEMENT

I, , an individual official, employee, consultant, or subcontractor of or to

(the Authorized Entity), intending to be legally bound, hereby consent to the terms in this

Agreement in consideration of my being granted conditional access to certain information, specified below, that is owned by, produced by, or in the possession of the United States Government.

(Signer will acknowledge the category or categories of information that he or she may have access to, and the signer's willingness to comply with the standards for protection by placing his or her initials in front of the applicable category or categories.)

I attest that I am familiar with, and I will comply with all requirements of the PCII program set out in the Critical Infrastructure Information Act of 2002 (CII Act) (Title II, Subtitle B, of the Homeland Security Act of 2002, Public Law 107-296, 196 Stat. 2135, 6 USC 101 et seq.), as amended, the implementing regulations thereto (6 CFR Part 29), as amended, and the applicable PCII Procedures Manual, as amended, and with any such requirements that may be officially communicated to me by the PCII Program Manager or the PCII Program Manager's designee.

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of SSI information as cited in this Agreement and in accordance with 49 CFR Part 1520, "Protection of Sensitive Security Information," "Policies and Procedures for Safeguarding and Control of SSI," as amended, and any supplementary guidance issued by an authorized official of the Department of Homeland Security.

As used in this Agreement, sensitive but unclassified information is an over-arching term that covers any information, not otherwise indicated above, which the loss of, misuse of, or unauthorized access to or modification of could adversely affect the national interest or the conduct of Federal programs, or the privacy to which individuals are entitled under Section 552a of Title 5, as amended, but which has not been specifically authorized under criteria established by an Executive Order or an Act of Congress to be kept secret in the interest of national defense or foreign policy. This includes information categorized by DHS or other government agencies as: For Official Use Only (FOUO); Official Use Only (OUO); Sensitive Homeland Security Information (SHSI); Limited Official Use (LOU); Law Enforcement Sensitive (LES);

Safeguarding Information (SGI); Unclassified Controlled Nuclear Information (UCNI); and any other identifier used by other government agencies to categorize information as sensitive but unclassified.

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of the information to which I am granted access as cited in this Agreement and in accordance with the guidance provided to me relative to the specific category of information.

I understand and agree to the following terms and conditions of my access to the information indicated above:

1. I hereby acknowledge that I have received a security indoctrination concerning the nature and protection of information to which I have been provided conditional access, including the procedures to be followed in ascertaining whether other persons to whom I contemplate disclosing this information have been approved for access to it, and that I understand these procedures.

2. By being granted conditional access to the information indicated above, the United States Government has placed special confidence and trust in me and I am obligated to protect this information from unauthorized disclosure, in accordance with the terms of this Agreement and the laws, regulations, and directives applicable to the specific categories of information to which I am granted access.

3. I attest that I understand my responsibilities and that I am familiar with and will comply with the standards for protecting such information that I may have access to in accordance with the terms of this Agreement and the laws, regulations, and/ or directives applicable to the specific categories of information to which I am granted access. I understand that the United States Government may conduct inspections, at any time or place, for the purpose of ensuring compliance with the conditions for access, dissemination, handling and safeguarding information under this Agreement.

Initials: Protected Critical Infrastructure

Initials: Sensitive Security

Initials: Unclassified (SBU)

DHS Form 11000-6 (8/04) Page 2 of 3

4. I will not disclose or release any information provided to me pursuant to this Agreement without proper authority or authorization. Should situations arise that warrant the disclosure or release of such information I will do so only under approved circumstances and in accordance with the laws, regulations, or directives applicable to the specific categories of information. I will honor and comply with any and all dissemination restrictions cited or verbally relayed to me by the proper authority.

5. (a) For PCII - (1) Upon the completion of my engagement as an employee, consultant, or subcontractor under the contract, or the completion of my work on the PCII Program, whichever occurs first, I will surrender promptly to the PCII Program Manager or his designee, or to the appropriate PCII officer, PCII of any type whatsoever that is in my possession.

(2) If the Authorized Entity is a United States Government contractor performing services in support of the PCII Program, I will not request, obtain, maintain, or use PCII unless the PCII Program Manager or Program Manager's designee has first made in writing, with respect to the contractor, the certification as provided for in Section 29.8(c) of the implementing regulations to the CII Act, as amended.

(b) For SSI and SBU - I hereby agree that material which I have in my possession and containing information covered by this Agreement, will be handled and safeguarded in a manner that affords sufficient protection to prevent the unauthorized disclosure of or inadvertent access to such information, consistent with the laws, regulations, or directives applicable to the specific categories of information. I agree that I shall return all information to which I have had access or which is in my possession 1) upon demand by an authorized individual; and/or 2) upon the conclusion of my duties, association, or support to DHS; and/or 3) upon the determination that my official duties do not require further access to such information.

6. I hereby agree that I will not alter or remove markings, which indicate a category of information or require specific handling instructions, from any material I may come in contact with, in the case of SSI or SBU, unless such alteration or removal is consistent with the requirements set forth in the laws, regulations, or directives applicable to the specific category of information or, in the case of PCII, unless such alteration or removal is authorized by the PCII Program Manager or the PCII Program Manager's designee. I agree that if I use information from a sensitive document or other medium, I will carry forward any markings or other required restrictions to derivative products, and will protect them in the same matter as the original.

7. I hereby agree that I shall promptly report to the appropriate official, in accordance with the guidance issued for the applicable category of information, any loss, theft, misuse, misplacement, unauthorized disclosure, or other security violation, I have knowledge of and whether or not I am personally involved. I also understand that my anonymity will be kept to the extent possible when reporting security violations.

8. If I violate the terms and conditions of this Agreement, such violation may result in the cancellation of my conditional access to the information covered by this Agreement. This may serve as a basis for denying me conditional access to other types of information, to include classified national security information.

9. (a) With respect to SSI and SBU, I hereby assign to the United States Government all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of the information not consistent with the terms of this Agreement.

(b) With respect to PCII I hereby assign to the entity owning the PCII and the United States Government, all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of PCII not consistent with the terms of this Agreement.

10. This Agreement is made and intended for the benefit of the United States Government and may be enforced by the United States Government or the Authorized Entity. By granting me conditional access to information in this context, the United States Government and, with respect to PCII, the Authorized Entity, may seek any remedy available to it to enforce this Agreement including, but not limited to, application for a court order prohibiting disclosure of information in breach of this Agreement. I understand that if I violate the terms and conditions of this Agreement, I could be subjected to administrative, disciplinary, civil, or criminal action, as appropriate, under the laws, regulations, or directives applicable to the category of information involved and neither the United States Government nor the Authorized Entity have waived any statutory or common law evidentiary privileges or protections that they may assert in any administrative or court proceeding to protect any sensitive information to which I have been given conditional access under the terms of this Agreement.

DHS Form 11000-6 (8/04) Page 3 of 3

11. Unless and until I am released in writing by an authorized representative of the Department of Homeland Security (if permissible for the particular category of information), I understand that all conditions and obligations imposed upon me by this Agreement apply during the time that I am granted conditional access, and at all times thereafter.

12. Each provision of this Agreement is severable. If a court should find any provision of this Agreement to be unenforceable, all other provisions shall remain in full force and effect.

13. My execution of this Agreement shall not nullify or affect in any manner any other secrecy or non-disclosure Agreement which I have executed or may execute with the United States Government or any of its departments or agencies.

14. These restrictions are consistent with and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by Executive Order No. 12958, as amended; Section 7211 of Title 5, United States Code (governing disclosures to Congress); Section 1034 of Title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); Section 2302(b)(8) of Title 5, United States Code, as amended by the Whistleblower Protection Act (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats); the Intelligence Identities Protection Act of 1982 (50 USC 421 et seq.) (governing disclosures that could expose confidential Government agents); and the statutes which protect against disclosure that may compromise the national security, including Sections 641, 793, 794, 798, and 952 of Title 18, United States Code, and Section 4(b) of the Subversive Activities Act of 1950 (50 USC 783(b)). The definitions, requirements, obligations, rights, sanctions, and liabilities created by said Executive Order and listed statutes are incorporated into this agreement and are controlling.

15. Signing this Agreement does not bar disclosures to Congress or to an authorized official of an executive agency or the Department of Justice that are essential to reporting a substantial violation of law.

16. I represent and warrant that I have the authority to enter into this Agreement.

17. I have read this Agreement carefully and my questions, if any, have been answered. I acknowledge that the briefing officer has made available to me any laws, regulations, or directives referenced in this document so that I may read them at this time, if I so choose.

NON-DISCLOSURE AGREEMENT

Acknowledgement Typed/Printed Name: Government/Department/Agency/Business Address Telephone Number:

I make this Agreement in good faith, without mental reservation or purpose of evasion.

Signature: Date:

WITNESS:

Typed/Printed Name: Government/Department/Agency/Business Address Telephone Number:

This form is not subject to the requirements of P.L. 104-13, "Paperwork Reduction Act of 1995" 44 USC, Chapter 35.

NON-DISCLOSURE AGREEMENT

NON-DISCLOSURE AGREEMENT

WITNESS:

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

BADGE APPLICATION

PRINT ALL ANSWERS UNLESS SIGNATURE REQUESTED

Information provided by those completing this form may be used to conduct background checks on the applicant in accordance with FLETC Directive 71-01, Access Control. Privacy Act Statement: This information is provided in accordance with the Privacy Act of 1974 (5 USC 552a). Authority for this information is 5 USC 301, 5 USC 4101 et seq., Executive Order No. 11348, and Department of Homeland Security Delegation 7050. Disclosure of this information is voluntary.

Failure to provide requested information may result in denial of access to the FLETC property.

SECTION A - To be completed by Applicant

1. Applicants Full Name:

(Last, First, Middle)

Aliases Used (nicknames, maiden names, etc):

2. Residential Address: Street Address:

City, State, Zip code:

3. Driver's License: State Driver's License #:

4. Country of…