Final_RFP_A11_OSHA_Form_300A.xls
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- NBACC FFRDC Federal contract opportunity
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- HSHQDC-15-R-00050
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NBACC FFRDC Final RFP--Attachment 11 (OSHA Form 300A)
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OSHA Form 300
| 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. | |||||||||||||||||
| OSHA's Form 300 (Rev. 01/2004) | Year | ||||||||||||||||
| Log of Work-Related Injuries and Illnesses | U.S. Department of Labor | ||||||||||||||||
| Occupational Safety and Health Administration | |||||||||||||||||
| You must record information about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must complete an injury and illness incident report (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you're not sure whether a case is recordable, call your local OSHA office for help. | Form approved OMB no. 1218-0176 | ||||||||||||||||
| Establishment name | |||||||||||||||||
| City | State | ||||||||||||||||
| Identify the person | Describe the case | Classify the case | |||||||||||||||
| CHECK ONLY ONE box for each case based on the most serious outcome for that case: | Enter the number of days the injured or ill worker was: | Check the "injury" column or choose one type of illness: | |||||||||||||||
| (A) | (B) | (C) | (D) | (E) | (F) | ||||||||||||
| Case No. | Employee's Name | Job Title (e.g., Welder) | Date of injury or onset of illness | Where the event occurred (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) | ||||||||||||
| (M) | Skin Disorder | Respiratory Condition | Poisoning | Hearing Loss | All other illnesses | ||||||||||||
| Death | Days away from work | Remained at work | Away From Work (days) | On job transfer or restriction (days) | Injury | ||||||||||||
| (mo./day) | |||||||||||||||||
| Job transfer or restriction | Other record- able cases | ||||||||||||||||
| (G) | (H) | (I) | (J) | (K) | (L) | (1) | (2) | (3) | (4) | (5) | (6) | ||||||
| Page totals | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||
| Be sure to transfer these totals to the Summary page (Form 300A) before you post it. | Injury | Skin Disorder | Respiratory Condition | Poisoning | Hearing Loss | All other illnesses | |||||||||||
| Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review the instruction, search and gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Ave, NW, Washington, DC 20210. Do not send the completed forms to this office. | |||||||||||||||||
| Page | 1 of 1 | (1) | (2) | (3) | (4) | (5) | (6) |
OSHA Form 300A
| OSHA's Form 300A (Rev. 01/2004) | Year | |||||||
| Summary of Work-Related Injuries and Illnesses | U.S. Department of Labor | |||||||
| Occupational Safety and Health Administration | ||||||||
| Form approved OMB no. 1218-0176 | ||||||||
| All establishments covered by Part 1904 must complete this Summary page, even if no injuries or illnesses occurred during the year. Remember to review the Log to verify that the entries are complete and accurate before completing this summary. | ||||||||
| Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you've added the entries from every page of the log. If you had no cases write "0." | Establishment information | |||||||
| 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 1904.35, in OSHA's Recordkeeping rule, for further details on the access provisions for these forms. | Your establishment name | |||||||
| Street | ||||||||
| Number of Cases | City | State | Zip | |||||
| Industry description (e.g., Manufacture of motor truck trailers) | ||||||||
| Total number of deaths | Total number of cases with days away from work | Total number of cases with job transfer or restriction | Total number of other recordable cases | |||||
| Standard Industrial Classification (SIC), if known (e.g., SIC 3715) | ||||||||
| 0 | 0 | 0 | 0 | |||||
| (G) | (H) | (I) | (J) | OR | North American Industrial Classification (NAICS), if known (e.g., 336212) | |||
| Number of Days | Employment information | |||||||
| Total number of days away from work | Total number of days of job transfer or restriction | |||||||
| Annual average number of employees | ||||||||
| 0 | 0 | Total hours worked by all employees last year | ||||||
| (K) | (L) | |||||||
| Injury and Illness Types | ||||||||
| Sign here | ||||||||
| Total number of… | Knowingly falsifying this document may result in a fine. | |||||||
| (M) | ||||||||
| (1) Injury | 0 | (4) Poisoning | 0 | |||||
| (2) Skin Disorder | 0 | (5) Hearing Loss | 0 | I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete. | ||||
| (3) Respiratory Condition | 0 | (6) All Other Illnesses | 0 | |||||
| Company executive | Title | |||||||
| Post this Summary page from February 1 to April 30 of the year following the year covered by the form | Phone | Date | ||||||
| Public reporting burden for this collection of information is estimated to average 58 minutes per response, including time to review the instruction, search and gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Ave, NW, Washington, DC 20210. Do not send the completed forms to this office. |
&RHSHQDC-15-R-00050
Attachment 11
OSHA Form 301
| 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. | ||||||||||||
| OSHA's Form 301 | ||||||||||||
| Injuries and Illnesses Incident Report | U.S. Department of Labor | |||||||||||
| Occupational Safety and Health Administration | ||||||||||||
| Form approved OMB no. 1218-0176 | ||||||||||||
| Information about the employee | Information about the case | |||||||||||
| This Injury and Illness Incident Report is one of the first forms you must fill out when a recordable work-related injury or illness has occurred. Together with the Log of Work-Related injuries and Illnesses and the accompanying Summary, these forms help the employer and OSHA develop a picture of the extent and severity of work-related incidents. | ||||||||||||
| 1) | Full Name | 10) | Case number from the Log | (Transfer the case number from the Log after you record the case.) | ||||||||
| 2) | Street | 11) | Date of injury or illness | |||||||||
| City | State | Zip | 12) | Time employee began work | AM/PM | |||||||
| 3) | Date of birth | 13) | Time of event | AM/PM | Check if time cannot be determined | |||||||
| 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. | 4) | Date hired | 14) | 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." | ||||||||
| 5) | Male | |||||||||||
| Female | ||||||||||||
| Information about the physician or other health care professional | ||||||||||||
| 15) | What happened? Tell us how the injury 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." | |||||||||||
| 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 | 6) | Name of physician or other health care professional | ||||||||||
| If you need additional copies of this form, you may photocopy and use as many as you need. | 7) | If treatment was given away from the worksite, where was it given? | ||||||||||
| Facility | 16) | 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." | ||||||||||
| Street | ||||||||||||
| City | State | Zip | ||||||||||
| 8) | Was employee treated in an emergency room? | |||||||||||
| Completed by | Yes | 17) | What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank. | |||||||||
| No | ||||||||||||
| Title | ||||||||||||
| 9) | Was employee hospitalized overnight as an in-patient? | |||||||||||
| Phone | Date | Yes | ||||||||||
| No | 18) | If the employee died, when did death occur? Date of death | ||||||||||
| Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Ave, NW, Washington, DC 20210. Do not send the completed forms to this office. |
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