Fill and Sign the Incident Report Form

OSHA FORM 301 - Injuries and Illnesses Incident Report This form helps the employer and OSHA develop a picture of the extent and severity of work-related incidents. File this report if the doctor has you off work or on restricted duty due to the injury. Employee & Case Information: Employee Name: ________________________________________________ Case Number: ______________________ (Work Comp Dept. will assign this number) Street: ______________________ City: _________ State: _______ Zip: _______ Date of Birth: _________ Date Hired: _______ Male: Female: Date of Injury or Illness: _________ Time Employee began work: _______ AM PM Time of Incident: _________ AM PM Time Cannot Be Determined Information about the physician or other health care professional: Name of physician or health care professional who treated you (If Known): _______________________________________________________________ If treatment was given away from the worksite, where was it given: _______________________________________________________________ Was employee treated in an emergency room? Yes No Was employee hospitalized overnight as an in-patient: Yes No Information about the Incident: 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. Examples: "Climbing a ladder while carrying roofing materials"; "Spraying chlorine from hand sprayer"; "daily computer key-entry." ________________________________________________________________________ ________________________________________________________________________ What happened? Tell us how the injury occurred. Example: "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; etc." ________________________________________________________________________ ________________________________________________________________________ What was the injury or illness? Tell us the part of the body that was affected. Be more specific than "hurt, pain, or sore". Examples: "Strained Back"; "Chemical burn to hand"; "Carpal Tunnel". ________________________________________________________________________ ________________________________________________________________________ What object or substance directly harmed the employee? Examples: "Concrete floor"; "Chlorine";"radial arm saw". If this question does not apply to the accident, leave it blank. ________________________________________________________________________ ________________________________________________________________________ If the employee died, when did death occur? Date of Death: ____________ (Return This Form to _____________________ in Human Resources--Call Extension ________ if you have any questions. PLEASE ANSWER ALL QUESTIONS AS COMPLETELY AS POSSIBLE. OSHA REQUIRES EXPLANATION OF ALL ACCIDENTS AND HOW THEY HAPPENED.