ID05170010_Section_J_-_Attach_3_OSHA.pdf

U.S. Department of Labor Occupational Safety and Health Administration

OSHA’s Form 300 (Rev. 01/2004) Year 20__ __ Log of Work-Related Injuries and Illnesses You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you’re not sure whether a case is recordable, call your local OSHA office for help.

Form approved OMB no. 1218-0176

Page ____ of ____

Sk in d is or de r

R es pi ra to ry co nd iti on

Po is on in g

H ea ri ng lo ss

A ll ot he r ill ne ss es

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

Page totals

Establishment name ___________________________________________

City ________________________________ State ___________________

In ju ry

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

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

month/day month/day month/day month/day month/day month/day month/day month/day month/day month/day month/day month/day month/day

Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review the instructions, search and gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.

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

(M)

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

Death Days away from work

On job transfer or restriction

Away from work

Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes.

CHECK ONLY ONE box for each case based on the most serious outcome for that case:

Job transfer or restriction

Other record-able cases

Remained at Work

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

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

Sk in d is or de r

R es pi ra to ry co nd iti on

Po is on in g

H ea ri ng lo ss

A ll ot he r ill ne ss es

In ju ry

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 days days days days days days days days days days days days days days days days days days days days days days days days

U.S. Department of Labor Occupational Safety and Health Administration

OSHA’s Form 300A (Rev. 01/2004) Year 20__ __ Summary of Work-Related Injuries and Illnesses

Form approved OMB no. 1218-0176

Total number of deaths

Total number of cases with days away from work

Number of Cases

Total number of days away from work

Total number of days of job transfer or restriction

Number of Days

Post this Summary page from February 1 to April 30 of the year following the year covered by the form.

All establishments covered by Part 1904 must complete this Summary page, even if no work-related injuries or illnesses occurred during the year. Remember to review the Log to verify that the entries are complete and accurate before completing this summary.

Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you’ve added the entries from every page of the Log. If you had no cases, write “0.”

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

Establishment information

Employment information

Your establishment name __________________________________________

Street _________________________ _______

City ____________________________ State ______ ZIP _________

Industry description ( )

Standard Industrial Classification (SIC), if known ( )

North American Industrial Classification (NAICS), if known (e.g., 336212) e.g., Manufacture of motor truck trailers e.g., 3715

(I ee the Worksheet on the back of this page to estimate.)

OR

Annual average number of employees ______________

Total hours worked by all employees last year ______________ f you don’t have these figures, s

Sign here

Knowingly falsifying this document may result in a fine.

I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete.

Company executive Title

Phone Date

Public reporting burden for this collection of information is estimated to average 50 minutes per response, including time to review the instructions, search and gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.

Total number of . . .

Skin disorders ______

Respiratory conditions ______

Injuries ______

Injury and Illness Types

Poisonings ______

Hearing loss

All other illnesses ______

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

(K) (L)

(M) (1)

(2)

(3)

(4)

(5)

(6)

Total number of cases with job transfer or restriction

Total number of other recordable cases

At the end of the year, OSHA requires you to enter the average number of employees and the total hours worked by your employees on the summary. If you don’t have these figures, you can use the information on this page to estimate the numbers you will need to enter on the Summary page at the end of the year.

For example, Acme Construction figured its average employment this way:

For pay period… Acme paid this number of employees…

1 10 2 0 3 15 4 30 5 40

24 20 25 15 26 +

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

Add

Count

Divide

Round the answer the total number of employees your establishment paid in all pay periods during the year. Include all employees: full-time, part-time, temporary, seasonal, salaried, and hourly.

the number of pay periods your establishment had during the year. Be sure to include any pay periods when you had no employees.

the number of employees by the number of pay periods.

to the next highest whole number. Write the rounded number in the blank marked Annual average number of employees.

The number of employees paid in all pay periods =

The number of pay periods during the year =

The number rounded =

How to figure the total hours worked by all employees:

Include hours worked by salaried, hourly, part-time and seasonal workers, as well as hours worked by other workers subject to day to day supervision by your establishment (e.g., temporary help services workers).

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

If this number isn’t available, you can use this optional worksheet to estimate it.

Optional

Worksheet to Help You Fill Out the Summary

U .S

D e p a rt m e n t o f

L a b o r O c c u p a ti o n a l S a fe ty a n d

H e a lt h A d m in is tr a ti o 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

U.S. Department of Labor Occupational Safety and Health Administration

OSHA’s Form 301 Injury and Illness Incident Report

Form approved OMB no. 1218-0176

This is one of the first forms you must fill out when a recordable work-related injury or illness has occurred. Together with the and the accompanying these forms help the employer and OSHA develop a picture of the extent and severity of work-related incidents.

Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out this form or an equivalent. Some state workers’ compensation, insurance, or other reports may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the information asked for on this form.

According to Public Law 91-596 and 29 CFR

1904, OSHA’s recordkeeping rule, you must keep this form on file for 5 years following the year to which it pertains.

If you need additional copies of this form, you may photocopy and use as many as you need.

Injury and Illness Incident Report

Log of Work-Related Injuries and Illnesses

Summary, Information about the case

Case number from the

Date of injury or illness

Time employee began work

Time of event Check if time cannot be determined

Date of death

Log _____________________ (Transfer the case number from the Log after you record the case.)

AM / PM

AM / PM �

What was the employee doing just before the incident occurred?

What happened?

What was the injury or illness?

What object or substance directly harmed the employee?

If the employee died, when did death occur?

Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. “climbing a ladder while carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.”

Tell us how the injury occurred. “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker developed soreness in wrist over time.”

Tell us the part of the body that was affected and how it was affected; be more specific than “hurt,” “pain,” or sore.” “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.”

“concrete floor”; “chlorine”;

“radial arm saw.”

Examples:

Examples:

Examples:

Examples:

If this question does not apply to the incident, leave it blank.

Completed by

Title

Phone Date

Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.

10)

11)

12)

13)

14)

15)

16)

17)

18)

1)

2)

3)

5)

6)

7)

8)

9)

4)

Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes.