15._ATTACHMENT_11_OSHA_Form_300.pdf

RFP HSFLGL-17-R-00001

Dorm Management Services

FLETC, Glynco Georgia Attachment 11

OSHA

Forms for Recording Work-Related Injuries and Illnesses

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Dear Employer:

This booklet includes the forms needed for maintaining occupational injury and illness records for 2004. TI1ese new forms have changed in several important ways from the 2003 rccordkeeping forms.

In the December 17, 2002 Federal Register (67 FR 77165-77170), 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 bas made several changes to the forms package to make the recordkeeping materials clearer and easier to use:

On Fonn 300, we·ve s,litched the positions of the day count columns. The days "away from work" column now comes before the days "'o n job transfer or restriction."

• We've clarified the formulas for calculating incidence rates.

• vv·eve added new recording criteria for occupational hearing loss to the ..Overview.. section.

• On Fonn 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.

Occupoiumal Safety and Health Administration U.S. Department of Lahar

'Y Wo1*sheet to Help You Fill Outthe Summary -A work.sheet for figuring the average number of employees who worl:.cd for your establishment and the total number of hours worked.

'Y' OSHA 1s 301: Injury 11.nd Illness Incident

Report - A copy of the OSHA 301 to provide details about the incidenL 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. visit u, onllne atwww.osha.gov or call your local OSHA office.

We'll be happy to help you.

What's Inside...

In this package, you'll find everything you need to complete OSHA's Log and the Summary of ltorl,-R£!ated Injuries aml llln<.,.m for the next several years. On the following pages, you·n find:

T An Overview: Recording Worlc..ffelated ln/urles and Illnesses - General insrructions for filling ou t the forms in this package and definitions oftenns you should use when you classify your cases as injuries or illnesses.

'Y How to Fill Outth& Log -An example to guide you in filling ou t the Log properl y.

'Y Log of Worlc•Related Injuries and

Illnesses - Several pages of the Log (but you may make as man y copies of the Log as you need.) Notice that the Log is separate from the Summary.

T Summary of Worlc•Related lnJurlos and

1llneS$es- Removable Su11tma1)' pages for easy posting at the end of the year.

Note that you post the Summary only, not the Log.

http://www.osha.gov/

.Dorm Management Services

. FLETC, Glynco Georgia Part 9, Attachment 11

An Overview:

Recording Work-Related Injuries and Illnesses

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The Occuprulonal Safety and Health (OSH) Ac.tof 1970 require:; certiJin employers to prepare and maintain record!: of work-related in/wies and illnesses. Use these definitions when you classify cases onthe Lt,g. OSHA's r8CCfdkeeplng regular/on (see 29 CFR Pait 1904) provides more lnforrnarkm about the definitions betow.

What do you need to do?

1. Within 7 cale nda r days after you receive information about a case, decide if the case is recordable under the OSI-1.\ recordkeeping requirements.

The Lngnf Wark-RtlaJ-td Injuries and JJ/ne,c;. .s (Form 300) is used to cb.c;sify work-related injuries and illnesses and to note the extent and severit\• or each case. When an incident occun.. use·the Leg to record specific <lernH.s about what happened and how it happened.

The Smmnary - a. separate rorm (Fon n 300A)

- shows the roruls for the vear in each category. Al the end of the.year, post the Stmmwry in a \'isible location so th.at your employees are a¥.-are of the injuries and illnes ses occurring: in their workplace.

Employers must keep a l.og for each establishment or site. If you have more than one establishment, you must keep a separate U4J and Smmnary for each physical location that is expected ro be in oper.i.tion for one year or longer.

Note that rour employ ees haw· the right to review your injury and illness records. For more information, see 29 Code of Federal Regulations Part 1904.3,5 Empfuyte Jnvoli•mirnt.

Cases listed on the J..og of lVorlc-Rdo.Jed lnjuTU'S and Jll cs arenotnecessarily eligible for workers' compensation or other insurance benefits. Listing a case on the I..og does not mean that the employer or worker w·.is at fuult or that an OSHA standard was violated.

When ls an Injury or Illness considered work-related?

An h1jury or illnl:'.'!lS is considered work-rda1ed ifan <.'vent or exposure in the work environmem caused or contributed 10 the condition or significantly aggravated a preexisting condition. Work-relatednessis presumed for injuries and illnesses resulting from event.-. or exposures occurring in tl1c workp lace, unlt!SS an exception specifically appliC$. See 29 CFR Part I904.5(b)(2) for the exceptions. The work environment includes the estabfo,hruent and other locations where one or more employees are working or are present as a condition oftl1eir employmenL See 29 CFR P..i.rt 1901. 5 (b )(l ).

Which work•relnted injuries and illnesses should you record?

Record those work-related injuric.'> ::md illnesses th.:i.t result in:

T death, "'f' loss of consciousness, "'f' days av.-ay from work, "'f' restricted work activity or job transfer, or "'f' medical treatment beyond fir:n a.id .

You must also record wol'k-reL'lted injuries and illnesses that an: significant (as defined below) or meet any of the additional criteria listed below.

You musr record any significant work-related hijury or illness diat is db.goosed b}' a physicbn or other licensed health care professional. You must record any wmk-rdatecl case im·olving cancer, chronic ir rc: vcNiblc disease. a fractured or cracked bone, or a punaured eardrum. Sec 29 CFR 1901.7.

What are the additional criteria?

You must rec01·d the following conditions when they are work-relared:

T any needlc:.tick injury or cut from a sharp object that is contamin:itcd with another person's blood or otl1cr potentially infectious material:

"'f' any case requiring an employ 10 be medically remo,,ed under the requirements ofan OSHA heaJth standard;

"'f' tuberculosis infection as evidenced by a positive skin test or diagnosis by a ph)'Sician or other licensed health care professional after exposure to a known ClSt' ofactfre tubcrculo is.

T an employee's hearing test (audiogram) reveals 1) th.at tlieemployee hns experienced a Standard TI1reshold Shift (STS) in hc-aring in one or both ears (a,·eraged at 2000. 3000, and '1000 Hz) and

2) the employi:c's tocJ hearing level is 25 decibels (dB) or more above audiometric zero ( also :l\'eraged at 2000. 3000, and 4000 Hz) in the same car(s) as tl1e SI'S.

What is medical treatment?

Medical o·eatment includes managing and caring for a patient for tl1e purpose of combating di. ase or disorder. The following a.re not cons id e red medical treatments and are NOT recordable:

"'f' ,,h,,;cs. to a doctor or health care profes..<1.ionnl solely for obser'\'.ttion or counseling;

2. Determint:" whether the incident is a new case or a recurrence of an exisring one.

3. Esrnblish whether the: case was work-related.

4. If the case is recordable, decide which form you will fill out as the injury and illue:.s incident repo11.

You may use OSHA's 301: fojuryand Illness Incident Report or an equivalent form. Some state workers compensa-tion . insurance, or other reports may be acceptable substitu tes, as long as they provide the same information as the OSIL>\ 30 I.

How to work with the Log

1. Identify tl1e employee involved unless it is a privacy concern case a!I described below.

2. Identify whe n and 1,·herc the case occuned.

3. Descn"be the ca.._e, as specifically as you

4. Classify the sc1;o usncss of the case by recording the most serious outcome associated with the cn.se, witl1 column G (Death) being the most serious and columnj (Other recordable cases) being the least serious.

5. ldentll}· whether tl1e case is an injury or illness. If tl1e case is an injury, check the injury category. lfthc case is an illne:.s. cht:1:k tl1e appropriate illness rategory.

_ Dorm Management Services

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T diagnostic procedures. including administering prescription medications that are ust:d solely for diagnostic purposes; and

'f' any procedure tk1t can be labeled first aid.

(SubrluwJo-r mon> infonnaJion nbmtl Jin:! aid.)

What is first aid?

If the incident required onl)' the follO\\ing types of treannent . consider it first :.t.id. Do NOT record the case ifit in\'olvcs only:

T using non-prescription medications at non-prescription strength:

T administering tetanus immunizations:

"f" cleaning, flushing, or soaking wounds on the sl:in surface:

T using wound co,1erings. such as bandages.

Band.A.ids'", gauze pads,. etc., or using SteriStrips"" or butterfly b:mcbges.

T using hot or cold therapy.

T using any totally non-rigid means of support.

such as elastic b;mdagcs. wr.tps, non-rigid back belts, etc.:

T using temporary irnmobili7.ation devices while transporting an accident victim (splints, slings, neck collars. or bad:. boards).

Y drilling a fingernail or toenail to relieve pressure, or dr:ii.ning fluids from blisters:

Y using eye patches:

T mi;ing simple irrigation or a couon swab to removt:· foreign bodies not embedded in or adhered to the eye:

Y using irrigation, tweezers, cotton swab or other simple me.'Uls to rem ove splinters or foreign maLerial from areasother than the eye;

T using finger guards:

Y using massages;

Y drinking fluids to rclic,·c heat so-css

How do you d&eide ii the case involved restricted work?

Restricted worl:. activi1:y occurs when . as Lhe result ofa work-related injury or illness, an employer or health care professional keeps. or recommends keeping. an employt:c from doing Lhe routine functions of his or her job or from working the full worl:.d.ay th.at the emp loyee would have bt.-en scheduled to work. before the i jur y or illness occurred.

How do you count the number of days of restricted work activity or the number of days away from work?

Count the number or calendar days the employee v..i.s on restri cted work activity or v,as 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.aftr:r. the incident occurs. If a single injury or illnt"SS involved both d.,ys awa · from work and d."l)'S of restricted worl:. activity , enter the total number of days for each. You may stop counting day:; of restricted work activit y or days away from work once the total of either or the combination of both reaches 180 days.

Under what circumstances should you NOT enter the employee's name on the OSHA Form 300?

You mu."t consider the following types of injuries or illnesses to be pri\'acy concern cases:

T an injury or illness to an intimate body part or to the reproductive system, Y an injury or illnt>S!> resulting from a se>..--ual nssaulL Y a mental illne.-s, Y a case of HIV infection. hepatitis, or tuberculosis, Y a ncc.-dlestic:k injtlry or cut from a slmrp object that is contamin;:ited wilh blood or other potentially infectious material (see 29 CFR Patt 1901.8 for definition). and

T other illnesses. irthc employee independently and voluntarily requests th.at his or her name not be entered on the log.

You must not enter the employee's name on the OSHA SOO Log for these cases. Instead. enter Mprivacy CJ.Se" in the spaa: normally used for the employee's name. You must keep a separate.

confidential lisl of the case numb,..rs and emploree names for the- establishment's privacy concern cases so that you can update the c1.ses and provide information to the gm•emmcnt if asked to do so.

If ·ou have a reasonable basis to believe that information descnOing the pri\'acy concern case may be personally identifiable e\'cn though the emptoree's name hashcen omitted, you may use discretion in describing the injury or illness on both the OSHA 300 and 30 J forms. You must enter enough information to identify the cause of the incident and the general sc,•ericy of the injury or illness, hut you do not need to include details of an intimate or pri\'atc nature.

What ff the outcome changes after you record the caso?

Ifthi: outcome or extent ofan injury or illncM changes after you ha\'e recorded the c::isc, simply draw a line through the original entry or, if you wish. delete or whitc--out the original entry. Then write the new entry where it belongs. Remember, you need to record the most serious outcome for each case.

Classifying injuries An injury is ;my wound or damage lo the body resulting from ::m e,·em in the work.

en,;ronment.

Examples: Cut. puncture. L,ceration.

abrasion. fracture, bruise, contusion, chipped tooth, amputation, inSt"ct bite, dectrocution, or a thermal. chemiol. dea:riol. or radiation bum. Sprain and strain injm;es to muscles, joints, and connective tissues are classified as injuries when they result from a slip, trip. full or other im.ilar ::i.ccidcnt.".

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Classifying illnesses

SJcln d1S4NISOS or dborders Skin diseases or disorders are illnesses involving the worker ' s skin thal are CJ.u sed by wor k e xposure to che mic \ls. pl-luts . or ol..litr sub stan ces.

ba mpk:s: Contact dermatitis, CC7.t'ma. or r.lSh cm sed by prima ry irritants and sensiri:u.:n;

cadmi um, arsenic. or other meta.ls; poisoning by rarbon mono xide. hydrogen sulfide. or oth er g- .l.SC$; po isoning by benzene, benwl. carbon ttt.r.

1chlo ride . or ot her org-.m.ic wl vcnts;

poi. ning by insecticide spra sy . such as par.ilhiooor lt:ad arsenate: poisoning b)· other chcmiai ls, such a,.; formaldehyde.

When must you post the Summary?

You must post the Summary• o n l y - not th e Log- by FebntarJ· l of the year foUo wing the yar cove red by the fonn and keep it po sted until April 30 of that yea r.

chrome ulcers: inOamm.i.tion or the skin.

Respirat ory co nditi ons R.esp ir.ltoryrcon dit io n s are illnesses associated with bre:nhing hazardo us biological agents, chemicals, du st. g.ises, , .i.pors, or fumt."ll a t work.

Examples: Silicosis. asbestosis, pncumonitis, pharyngitis, rhinitis or acute congestion;

f".u,n c r' s lung. beryllium disease, tube rculosi occupation:tl aschnu . r ea cti\'e ain \·ays dysfunction !i)'ndrome (RADS}. chronic obstructive pulmotUry disease (COPD).

hypersensitivity pneumonifu, tox.ic inhalation injur y. such as met:ll fume fe,·er, chronic obstructive bronch i1is, and other pneumoconioscs.

or po isonous plants; oil acne; friction blisters.

Heari11g loss Noise-induced hearing loss i..; d efined for recordl;t-.eping purposes as a change in hearing threshold relative t.o the baseline audiogram of :m a.ver.ige of IO dB or mo re in either era at 2000 . 3000 and 4000 hertt , and rhc emp lo yee's total hear ing level b; 25 dcd be l1 (dB) or more :tbovc au di1>metric 1.cro (also averaged at !WOO, 3 000, and 4-000 hertz) in the same ear(s) .

How long must you keep the Log and Summary on file?'

You must keep the Log and Sw,mlQ1. )' for 5 years fo llowing the year to which they pertain.

Pol.eon/ng Poisoning includes disorders evidenced by abnorm al conccntratioru of toxic substauccs in blood, other tis!lucs. other bodily fluids , or the breath tll;u are caused by the ingestion or absorption oftox.ic substances into the body.

E.xa.mpks: Pi.>iso nin g b y lead. mercu ,ry

All othor lllnHStts AH other occup;1tional illnesses.

Examp1es: Hea t.stro ke, sunmoke. heat exhaustion. heat stress and orher effcas of emi ronmco c:il hear; freezing. frostb ite , a nd other effl!CU o f ex posure co low temperatures;

decompression sickness; effects of ion izing r.ldia.tion (isotopes, x-rnys. radium ); effects of nonionizingr .tdiation (wdding flash, ultra-violet r:iys. lasers ); an thrax. ; bloodbomc pathogenic diseases. such as :\I DS, Hn : hepa ti tis B or hcp:i.titis C; brucellosis: rn::t.lignant or be nign tumors: histoplasmosis ; coccidio idomycos is.

Do you have to send these forms to OSHA at the end of the year?

No. You do not have to send the completed forms to OSHA un less specifically asL:cd to do so.

How can we he lp you?

Jf you have a question about how to 611 out the Log, a visi t us onlln • at www -osha g. ov o r

Q call your local OSHA offi ce.

IMtMl&ii Calculating Injury and Illness Incidence Rates .= ·---...:._"""'""'= .....\...-:&I!:'.. . .=-=--:==. . -

What is an incidence rate?

.An inciden ce r::ite is the number of recordable injuric.<1; a nd illn , cs occurring among a gi\'en number of full-time work.c (usually 100 full-time workers} o,·er a given period or time (usuo1lly one ye:ir). To C\'a.lua.tc your firm's injur,·:ind illness ex perience over rime or to compare your 6rm's experience with dut of your industry as a whole, you need 10compurc your incidcno: r'dk. Because a c number of workers and a specific period of time arc involved . these ratescan help you iden tify problems in your workplace and/or prob"l"ess

(H) on the OSHA Form 300A.

(c) T/11: number of hmm all emp/ny,:6 actually v101' d d1tring // ytar. Refer to OSHA Form 300A and optional worksheet to c:tlrulatc this number.

You can compute the incidence rate for all recordable c.ases of injuries and illnt:SSt:$ using the following form ula :

Total numbrt- of injuries mul ilbwssrs X 200,0(J{J + Nim1Wr of lunm worl:rd by nil nnp!.oy,es = Tu/al rl'rordt1hltrn.umle

(Ille 200,000 figure in the formula represents

\'arious classifo.:ations (e.g., by industry, by emp loyer size, ere.). You can obtain tllese publi:.hed data at www.bls.go\'/iif or by calling a Bl.S Regional Office.

Worksheet

Number of you nuy fun: made in preventing worl..-rd tcd injuries and illnelise:i.

How do you calculate an Incidence

Lhc nu mbe r of hours JOO employec.."S working 40 hours per week. 50 1\•ctk."1. per year wou ld work, and provides the standard base for calculating incidence rates.)

Tout number or hours worked injuries and illnesses by all employees

X 200,000 +

Total recordable:

ctsc rate rate?

You cm compute an occupational injury and iUn ess incid e nc e rnlc for all recordable Clst$ or forCJ.Ses that invol\'ed days away from work for your firm quickly and easily. The formula require, that )'Ou follow instructions in p:irabry;iph (a} below for the total recordable

ca. or1.hosc in paragraph (b) for cases that

You can compute the incidence rate for recordable casc..-s in\'oh-ing days away from work, days of restricted work activity or job transfer (DART) using the following formula:

(Number of mlrir.s in column H + N1imber of enJries ffi colum11 l) X 200,000 + N,rmbrr of hours ll'&rl;td by all i7nfalf1Jee'i = Dtllffindden.uroU

Number of invoh·ed d.iy,i awa r from woi-1:., and for both r.u.e s the in,;tructions in paragraph (c).

(a) To fmd out till' total numbuof rcamlabk injwin and illnfflCS //1111 occurred d1tring II yr.ar, You can use the same fonnula lo C'.tlculatc incidence rates for other variables such as cases im·olving restricted work acti\'ity (column(]) on Form 300A), cases invoking sl<ln disorders

Number of entries in hours worked Column H + Column I hr all employ

X 200,000 +

DART incidence r.ne count the number of line eutries on your OSHA Form 300, or refer to tl1c OSHA. Form :IOOA :md sum the cnuies forcolumns (G). (H), (!), and (I).

(b) 1ujinrf out /ht mm1herof;njurirsand Ul1U!SSl'S tlwl ;nt'Ol:xd days aUJfly from work, count the number of line entries on your 051-U.

Form 300 that recci\'cd a check mark in column (H), or refer to rhe entry for column

(column (M-!!) on Form 300A}. ere.Just subsdnne the appropriate total for these cases.

from Form 300A. into the formula in place of thermal number of injuries and illncsse-..

What can I compare my incidence rate to?

The Bur e::m of Labor Statistics (BlS) conducu, a sun•ey of occupational injuries and illnesses each ye:u- and publishes incidence ra.te d:im by separate records for each physical location Mf.ffifii til d ;.

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How to Fill Out the Log The J..,og of Worh-Relatc'd Injurit!s anti lllrk!sses is used to classify work-related injuries and illnesses ::md to noLe the e xten t and seve rity of each case. When an incident occurs, u:-e the Log to record specific details about what

OSHA's Form 300 i- . 01/200<) l.og of Work-Related Injuries and Illnesses

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Year20 (a happened and how it happened.

If your compan y has more than one establishment or site , you must keep

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Th e Summary - a separat e form -shows the work-related injury and illness

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.J..,I,ua ,!!,,J,!1- .\fa,, / lnror r. ... ',..'!J r:1- J _ .... o a a o 0 0 _ ..... _ ...... a a C CC to tals for the year in each category. At the end of the year. count the number of ---

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CJ CJ CJ _...,.._J.r. a a c a a incidents in each category and transfer the to1als from c.hc Log to the Sr,mmary. Then post tlie Smm1lll1 J in ,a ·isible location so that your cmplo r ees ;-ire aware of injuries and illnesses occuni ng in their workp lace.

You don't potJt the Log. Youpost only tho Summary at tl'lo ond ol tho yoar..

Aovl.s. UJ. log JI tho ln/u,yor Ill-• progre... • .and tho outcomo ls mo,.

Hrlou• ttum you orlglnally roconlod tor tho era- out,oraso, or wh/UHJut tho orlgln11I ont,y.

Choo.ct ONLY ONE ot those catogorlo.. ClaNlfy thocno by recording th• mo•t -rfous ouccom. ot Cho cau, with column G (DNthJ Hing Che most .. r1ous and column J (OUtor rocordabl• c• ... J "-Ing tholout Hrfou..

Hofe wMthor the lnvotv- an ln/ury or an llbtess..

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Attention: This form contains informationrelatingto OSHA Form 300 (Rev. 01/2004) employee health and m st be used in a mannerthat protects the confidentiality of employees to the extent Year 20 Log of Work-Related lniuries and Illnesses possiblew h iel theni form a t ion is beingused for U.S. Department of Labor

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You must record Information about eve,y work-related death andabout every work-rolated injury or Illness thar Involves loss of consciousness, restricted WOii< sctiviry or job transfer, days away from work, or medical trootment beyond first aid. You must also record significant work-re!EJted injuries and illnesses that a1e diagnosed by a physician or licensed health Cd!e professional. You mustalso record WOik-reiated 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 linesfor a single case if you need to. You must complete an Injury and J!lness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. ffyou·ro not surewhether acase fs recordable, call your local OSHAofftee tor help.

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Identify the person Describe the case Classify the case

(A) (B) (C) (D) (E) (F)

CHECK ONLY OH£ box for O,/Jch c.nso bnsod on tho most sorJous oulc:omo tor

Ent•r th• number of days tho lnjurod or Check U.. "'Injury' column or

C,,e Emplnytt's nnme Job title (r4;.. 11"-fdrrJ

Date of injury Where the evl!'D.I occurttd oronset (r.g•. l.Dading doclt nort/1 rod)

Describe iujury o..- illnes-. pAtU o(body :ufcct and objcctlsubstance that directly injured thnr cnso:

..... lromwof'II cw....trictlon ablotcuaa

=m =wo=rke-r=W9·a=l' =

·..-... resbfcUon chooso ono typo of IUnou.:

er-er::-

(G) (HJ (1) (J) (K) (L)

D D D D

(1) (2) (3) (4) (5) (6)

D D D D D D

I m-on1h-/d'a-y

D D D D _ d:iys _ <h}

D D D D _ ...,. _ ...,.

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I

D D D D - - d.iys

D D D D _ dll)'ll _ dzy,;

D D D D D D D D _ <b)-s _ J..

D D D D D D

D D D D D D

D D D D D D D D D D D D

- - - """""" D D D D _ ...,. _ ..... D D D D D D

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J>ub llc reoponin1t bnrden !Or thiiicoUC.'C'\lon oJ'luronn.adon i, eod f!Ullcd t<>:wi:r,11,.-c 11 mimn a per rnpun .including rime ro raicw the!n.\U'llaion,.>C:1rdi 11ndw u.h('J' thedie, nc·et!ed, :md complac nnd rr"l"ic"' d.e roUeal on oflnform:,.UOn. Pl"nOOI lll't' unf rcquir-,,1

D D D D _ d ') -

Page totals> &,:ure /0 traf/Sfe1 e l0/8/tJ to the Summ8JY paf]tJ (Form 3004) beforeyou Jr.

D D D D D D

-i 1{Fli '

16 n:spond to th,..collt.'Crion of iufonn:ation uni,:,., i1 tliip y..;, currrndy \'alid OMR control num hcT. If you h:l\c' nny cornmcn about rhC"<c: otlm:nc,, or any other 11,peall oft hi, d.it:t c:o!lea:lon. cor.txt t::S Dtpanmcntof 1.nbor. OSHA Office ofSt..il>dail Analy11ii.. Room N-36H, 00 Con.t.i1u1ion A1 nuc, NW. W.:i hington. DC 10. Do noi send 1hc oon1plcted fonn1to 1hi, office.

a J- ai

(1) (2) (3) (4) (5) (6) ri,;ltt fn"DT111 fro"' acetylme tore/,) or mude person ill ( .g., &rond tuglubunu on ofillnccs

-----""""1'",,' - D D D D

_ cb yn _ .,,,.

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D

---- rr.coirJ y D D D D D D D D D D

FLETC, Glyn.co Georgia Attachment 11 fo rm 11p pravcd OM8 no. l:.!lll,.(lt70

OSHA's Form 300A (Rev. 01/2004) Year 20 Work-Related Injuries and Illnesses ....,,..,.'::.5.:.,?::.r:.::::.n:. :::.=:

Summary of = -- ===-=··· ·=- -=.=:==..= ,=..---.-- --- --.=.:.== --··- - · ·--

All establishmentscovered by Part 1904 must completethis Summary page, even if no work-related Injuries or illnesses occurred dun"ng the year. Remember lo review the Log tover/f'y that the entries are complete end accurate before completingthis summary.

Using the Log, count the Individual entries you made for each category. Then write the totals below, makJ·ng sure you've added the entries from every page of the Log. If you hadno cases, write ·o.•

Employees, former employees, and their representatives have the right to review the OSHA Form 300 in Its entirety. They also have limited access ro Che OSHA Form 301 or Its equivalent See 29 CFR Part 1904.35, In OSHA·s recordkeeping rule, for further derails on the access provisions for these forms.

Number of Cases

TotJ.l number of TotJ.l n u mber of TotJ.l num ber of Tot:1.I num ber of dc,ths C:LSCS with d:iys ClSes withjob other record:i.b le away from work tr.msfcr or restriction oscs

(G) (H) (I) (J)

Number of Days

Tool number of d:iys :1w:1y from work

Tot::il n umber of days of job t:ransfor or rest riction

(K) (L)

Injury and Illness Types

Toul number of ..

(M)

(1) Injuries (4) Poisonings

(5) H c:i.rin g: loss

(2) Skin disorders (3 ) Respir.ito ry conditions

(6) All other illnesses

Post this Summary pago from Fobruary 1 to April 30 of tho yoar following the year covored by the form.

Pub Uc rcpo rting bt1tdcn ror thl1co llectlonor1 nromui Uo n l1 ei1tlm11tcd t.o 11vcrngc58 mln utct pcr tcspon •c,!nclu dJng tlmc t.o !i:w thc lnatructlo1111,• eurch wid b'!IUlcr thcd 111.1 ncedcd. 11nd complete wid ri:vlcw the colk'Cllon orlnl'ortn11tlon. Pcn.on1 IU"C not required to ,......pond t.o tht' coUC'Cllon oflnforrrw.tlon unless It dhplay,,. u a.inc ndy vuUd 0MB control number. If you h11vc uny comments llhoot thnc fflltlmlll<'• or llllf other 11>pccto: nfthb dlllll.co lli,ctlon, conlllct: US Dcpnrtmcnt oft.,.bor, OSHA Offic.i ofStli.tJ>.tlcnl Ana!ytb, Rnom N-36-W, 200 Comrt.Jrutlon Av..nuc, ?l.'W, W:i,hlngton, DC 20210. Do not ocnd the completed fomn to thl1 offic,,.

Establishment information

Youro•tabllMm • nt n.am • - - - - - - - - - - - - -

Stre e t

City St:1.tc ZIP

Industry description (r._1!., M,1m,jMt11f"I' cf mot.,,mid: 1mi/rrs)

Sund.ird Industrul Cb.ssificltion (SJq, ifknown (e.g., 3715)

OR

North AmeriCJn lndustrfal Cbssitiation (NAICS), ifknown (e.g., 336212)

Employment informat ion (lf yo11 dcm'1 /iavr 1lr=fl.f!.11Tes, u, 1h, fV, .,rb /J« ro n 1/Jrba ck ef r/1i1 " 'o (Sfi ,nau.)

Annu:i.l Jvcr:igt: numher of employ

Tot:i.1 hours worked by all employees l "t yc;ir

Sign here

Knowingly falsifying this document may result in a fine.

I certify that I hn.ve ex:imined this document :md that to the best of my knowledge the entries are true, accur::i.tc, :1nd complete.

· FLETC, Glynco Georgia Attachment 11

@IMl&/1 = l!J!C!r f!s._h L R OJ! f_i(! 0f.!f fl!t=!-_.A '1Ll1!ay.r= =-'

At.the end of the yew; OSHArequires you to encer the average number of employe!eS and the totaJ hours worked by your employees on the summary. Jfyou don't have these figures, you canuse !he Information onthis page to estimate the numbers you w/11 need to emer on the Summary pageat the end of the year.

How to figure the average number of employees who worked for your establishment during the year:

How to figure the total hours worked by all employees:

0 Add the total number of employc=es your CSL'\blishment paid in all pay periods during Lhc year. [nclude all employees: full-time, pan-time, temporary. seasonal, salatied, and hourly.

Th e numbt:r of employees O paid in all pay period • ----

6 Countthenumberofpay periods your t"Stablislunent had duiing the year. Be sure to include any pay periods when you had no employees.

Include hours worked by salaried, hourly. part-time and seasonal workers, as well as hours worked by olhcr workers subject to day to day supervision by your est.iblishmem (e.g., temporary help services worl.:.ers).

Do not include vacation, sick leave, holidays . or any other non-work time, even if employc!es were paid for it. If your establishment keeps records of only the hours pa.id or if you have employees who are not paid by I.be hour, please estimate the hours that the employees actually worked.

If this number isn't available, you can use thi" optional worksheet to escimare ir..

Tiienumberofpay periods during tho:: yc.,r .a

--- Optional Worksheet

@) Div/do the number of employees by the number of pay periods.

Flndthc number of full.time employees in your csrablishment for the ycai:

0 Round the answerto the nexl highest whole number. Wrile the rounded number in the blank marked An.mwl a.JL'Tage mtmlur of anpfo)·ea;.

X--- ·nu: nwnber rounded = o ---

Multiply by the numbcrofworl:: hours for a full-rime employee in a year.

TI1is is the number of full-time hours work t"d..

fuerx:unple, Acme Construction figured its average employment this '"':IY:

F«PQ'Pfflod... · Aome ,..ldthl• numberafempl

+--- Adthenumber of any overtime hours as wdl a,; the hours worked by other employees (parMime .

temporary. seasonal)

"' .4.-.0

Nllmbcr of=ployccs p.1.id = R30

Numbc:r of pay periods = 26 filQ - 31.92

31.92 rounds coJ2 f)

5...

::s

30 f) Round the answer to die next highest whole number.

Write the rounded number in the blank. marked Total hours wtYrkrd b)• a./1 cmpUlyu s last yrar.

+ll!

J:? is tbc anmwl :.rver;ige nllmbcr ofemployee::

i

OSHA's Form 301 Injury and Illness Incident Report

Information about the employee 111is Injury mid Illness lncide,u.&part is one of the

Information about the case I r

U.S. Department of Labor Ooc")JaUon.,al Sat.er•nd H••llh Admlni.tratlon -= = = c -=::= ;.·,=--= =

Funn approved 0MB 110, l';!li;..ol76 c.,.....)

first forms you must fill out when a recordable work- I) Falln:amr----------------- 10) Cu. numbn- tht- I.cg (Trrm.<fe1· Ilse c1is,i nwnl,,r, f r.,m lli.t Lt,g efl,r you n:rtmt tJ11 rcb.ted injury or illness has occurred. Together with the Log of Wm1:-Rel.ated Injuries and Illnesses and the accompanying Smnmar)', these forms help the employer and OSHA develop a picture oftbe extent

Street

Clty Sbate ZIP

I 11) D:i.lcofinjuryorillnc.u ! _ !

12) TIDle employee bcg:i;o work AM./ PM

13) Tuneofcvent AM/PM OCbeckifthneaum.otbcdetttmloed and severity of work-related incideoL-..

Within 7 calendar days after you receive information chat a recordable work-related injury or illness bas occurred. you must fill out this form or an equivalent. Some state workers ' compensation, insurance. or other repons may be acceptable substitutes. To be considered an equivalent form, S) Dn orbinh

4) Dntehirftl

5)0 MIiie

D Female

I 14) Whm was tho omployoo doing just boloro tho lncldont occurrod?'D6Cribc the activiry, as well as the tools, equipment. or materi:tl theemployee w:zs using. Be r.pecific. Exampks: "climbing D. luddcr while cnrrying roofing materials"; -spraying chlorine from hand spr:iyer..; ..dlilly computer Jce;·-entry."

1S) What happonod?Tcll U!I how the injury occurttd. E:camplcs: .. When ladder slipped on wet floor, worker 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 iule, you must keep

Information about the physician or other health care professional

6) NDmlC'orph}'IDeian or other hea.lth are profe11sioruJ -------fell 20 fecr"; -worker w:is spr:i.yed with chlorine when gnskct broke during replacement": "Worker devcloped sorenen in wrist over time...

this form on file for 5 years following the year to which it pertains.

rfyou need additional copies of this form. you may photocopy and m•e as many a."' you need.

1 7) Irttc:inncnt wu vcn y from the worb:itr. where w.u it sivcn

FaciHty _ __ _

S<ttcl

16) Whitt wa• tho injury or lllnos•,.Tell us thepart of the body that wasaffected and how it was:i.ffectcd; be more specific than''hurt."""pain." or sore." Examples: "str.&ined back":"chcmicnl burn, hand'·:"cnrpnl tunnel syndrome."

' I

City Sta

8) Wu employee treated in an emergency room?

D YCII

0 No

9) Wu employtt: bc,&pitalittd overnight .u an in--pati t?

0 y

0 No

ZIP !

[ 17) What object or substance dlroctly harmed the employeo?Em mpks.· "concrete floor"; "chlorine...;

'<radial arm saw." If lhis question docs not apply to l11t! h1ddent, lt!ave it blank.

II

I'uhlir" rc-p,ordng hun:k-11 tOrthi• rolkc1ion of information i• m:i1Nl 10 avm,gc '.!!.'? minut,.,,{M'r ,....pon..e, Including time for re,iewing hwructiotu. w:ard1iug ex1'ting d.,t:i .ourco.g;ithc,rlng ;md m.aint.'Unini;:the dab needed.;md compl g nnd re,ning 1he collection ofinto nn:uion. Pen.o1is nn,1101 required to ro.pond 10 I.he collt'Cl..ion ofinform.ition im!a:o it <liopl.1 -,; 11 curTt'm ,.ilirlOUBcontrol nnmbc:r. If you have any commenb about thi.o e,nim;iu, or any other pea.oftl1i,. Wta rollecrio11. iocludinir •og,::e,tion for reducing thi, bordcn. ronQct: US Dep.-inment o[L:ilior, OSJl.\ Office ofSt:iU,tic-..•l .\naly,i11, Room N-3f>44. 200 Con.1itution A1·enuc,. N\\ \\';uhington, DC 0210. Do ll">tk"Tld l.he <nmp lefed fonn.o In thi.onflkc.

Completed by _

Tide

Phone(_\ - Date _; _ I _

= =--= = = :,::: .= - i;:;;.;·:;;;·;·,.= ,=

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 pu'!'.oses.

1ft) II tho omployoo diod, whon did dooth occur'? D:itc ofdc.i.th / _ I

- FLETC, Glynco Georgia Attachment 11

If You Need Help..• If you need help deciding whether a case /s 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.

T Visit us online at www.osha.gov Federal Jurisdiction State Plan States Oregon - 503 / 378-3272

T Call your OSHA Regional office andask for the recordkeeping coordinator

Region I - 617 / 565-9860 Connecticut; Massachusetts; Maine; New Hampshfrc; Rhode Island

Alaska - 907 / 269-4957 Pueno Rico- 787 / 754-2172

Arizona - 602 / 542-5795 South Carolina - 803 / 734-9669 or Region 2 - 212 / 337-2378 Now York; New Jorsey

California - 415 / 703-5100 Tennessee- 615 / 741-2793

T Call your State Plan office "'Connecticut - 860 / 566-4380 Utah -801 / 530-6901 Reg;on 3 • 215 / 861-4900 DC; Dolowaro; Ponnsylvanla; West Virginia Hawaii - 808 / 586-91 DO Vermont - 802 / 828-2765

Region 4 - 404 / 562-2300 Alabama; Florida; Georgia; Mississippi

Indiana - 317 / 232-2688 Virginia - 804 / 786-6613

Iowa- 515 / 281-3661 Virgin Islands-310 / 772-1315 Region 5 - 312 / 353-2220 llllnols; Ohio; Wisconsin Kentucky - 502 / 564-3070 Washington - 360 / 902-5554

Reg;on 6 • 214/ 767-4731 Arkansas; Louisiana; Oklahoma; Toxas

Maryland - 410 / 527-4465 Wyoming- 307 / 777-7786

Michiga.n - 517 / 322-1848

Reg;on 7 - 816 / 426-5861 Kansas; Missouri; Nebraska

•Public Sector only Minnesota - 651 / 284-5050

Region 8 - 303 / 844-1600 Colorado; Montana; North Dakota; South Dakota

Nevada - 702 / 486-9020

*New Jersey - 609 / 984-1389

Reg;on 9 - 415 / 975-4310 New Mexico - 505 / 827-4230

*New York - 518 / 4.57-2574 Region 10 - 206 / 553-5930 Idaho Nonh Carolina - 919 / 807-2875 http://www.osha.gov/

· FLETC, Glynco Georgia Attachment 11

Have questions?

If you need help in filling out the Log or Summary. or if you have questions about whether a case is recordable, contact

us. \.Vc'll be happy to help you. You can:

T Visit us online at: www.osha.gov

T Call your regional or state plan office. You·11 find the phone number listed inside this cover.

http://www.osha.gov/