ALOrange Beach

15

month / day/

daysdaysReset 1 Jane Doe Widget Welder 1 18 Welding Area Burned Retinas – both eyes ● 2 ●

month / day/

daysdaysReset 2 William Smith Warehouse Worker 2 24 Storeroom Lumbar Strain ● 4 ●

month / day/

daysdaysReset 3 Nellie Kershaw Production Line Worker 5 18 Main Production Floor Respiratory Condition ● 2 14 ●

month / day/

daysdaysReset

month / day/

daysdaysReset

month / day/

daysdaysReset

month / day/

daysdaysReset

month / day/

daysdaysReset

month / day/

daysdaysReset

month / day/

daysdaysReset

U .S. De pa rt m e nt of La borOc c upa t iona l Sa fe t y a nd H e a lt h Adm inist ra t ion

OSHA’s Form 300 (Rev. 01/2004)Year 20Log of Work -Re la t e d

I njurie s a nd I llne sse sYou 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

Inju

ry

Skin

dis

orde

r

Res

pira

tory

co

nditi

on

Pa ge t ot a ls

Establishment name

City

Ent e r t he num be r of da ys t he injure d or ill w ork e r w a s:

Se le c t t he “I njury” c olum n or c hoose one t ype of illne ss:

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)De a t h

Da ys a w a y from w ork

On job t ra nsfe r or re st ric t ion

Aw a y from w ork

At t e nt ion: 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.

SELECT ON LY ON E box for e a c h c a se ba se d on t he m ost se rious out c om e for t ha t c a se :

J ob t ra nsfe r or re st ric t ion

Ot he r re c ord- a ble c a se s

Re m a ine d a t Work

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

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

Case no.

Job title (e.g., Welder)

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)

Date of injury or onset of illness (e.g., 2/10)

I de nt ify t he pe rson De sc ribe t he c a se Cla ssify t he c a se

Employee’s name

Pois

onin

g

Hea

ring

loss

All

othe

r ill

ness

es

W

All

othe

r ill

ness

es

Hea

ring

loss

Pois

onin

g

Res

pira

tory

co

nditi

on

Skin

dis

orde

r

Inju

ry

Form approved OMB no. 1218-0176

State

CSU Widget Factory

of

N ot e : Y ou c a n t ype input int o t his form a nd sa ve it . Because the forms in this recordkeeping package are “fillable/writable” PDF documents, you can type into the input form fields and then save your inputs using the free Adobe PDF Reader. In addition, the forms are programmed to auto-calculate as appropriate.

0 3 0 0 8 14 2 0 1 0 0 0

1 1Save Input Add a Form Page

OSHA’s Form 300A (Rev. 01/2004)Sum m a ry of Work -Re la t e d I njurie s a nd I llne sse s

Form approved OMB no. 1218-0176

Total number of deaths

Total number of cases with days away from work

N um be r of Ca se s

Total number of days away from work

Total number of days of job transfer or restriction

N um be r of Da ys

Post t his Sum m a ry pa ge from Fe brua ry 1 t o April 3 0 of t he ye a r follow ing t he ye a r c ove re d by t he 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.

Est a blishm e nt inform a t ionY our e st a blishm e nt na m e

Street

City

Industry description (e.g., Manufacture of motor truck trailers)

Standard Industrial Classification (SIC), if known (e.g., 3715)

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

I njury a nd I llne ss T ype s

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

U .S. De pa rt m e nt of La borOc c upa t iona l Sa fe t y a nd H e a lt h Adm inist ra t ion

Year 20

OR

North American Industrial Classification (NAICS), if known (e.g., 336212)

Em ploym e nt inform a t ion (If you don't have these figures, see the Worksheet on the next page to estimate.)

Annual average number of employees

Total hours worked by all employees last year

Sign he re

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 _____ / _____ / ______

0

N ot e : Y ou c a n t ype input int o t his form a nd sa ve it . Because the forms in this recordkeeping package are “fillable/writable” PDF documents, you can type into the input form fields and then save your inputs using the free Adobe PDF Reader.

State Zip

0

8

0

0

Save Input

0 3 0 0

14

2

1

CSU Widget Factory

21982 University LaneOrange Beach AL 36561

Widget Manufacturing

326199

2758675