Fill and Sign the Work Related Injuries Form

OSHA Form 300 Log of Work-Related Injuries and Illnesses Year 20       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 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, job transfer, days away from work, or medical treatment beyond first aid. Use more lines for each case if needed. Establishment name:       City:       State:       Identify the person Describe the case Classify the case (A) Case no. (B) Employee’s name (C) Job title (e.g., “welder”) (D) Date of injury or illness (E) Where the event occurred (e.g., “loading dock - north end” (F) Describe Injury/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”) Using these 4 categories, enter “1” in only the most serious result for each case: * Enter the number of days the injured / worker was: Enter “1” in the “injury” column or choose one type of illness: * (M) Death Days away from work Remained at workInjury Skin disorder Respiratory condition Poisoning Hearing Loss All other illnesses Job transf er or restric tion Other record- able cases Away from work On job transfer or restriction (G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6)                                     0 0 0 0     days     days 0 0 0 0 0 0                                     0 0 0 0     days     days 0 0 0 0 0 0                                     0 0 0 0     days     days 0 0 0 0 0 0                                     0 0 0 0     days     days 0 0 0 0 0 0                                     0 0 0 0     days     days 0 0 0 0 0 0                                     0 0 0 0     days     days 0 0 0 0 0 0                                     0 0 0 0     days     days 0 0 0 0 0 0                                     0 0 0 0     days     days 0 0 0 0 0 0                                     0 0 0 0     days     days 0 0 0 0 0 0                                     0 0 0 0     days     days 0 0 0 0 0 0                                     0 0 0 0     days     days 0 0 0 0 0 0                                     0 0 0 0     days     days 0 0 0 0 0 0                                     0 0 0 0     days     days 0 0 0 0 0 0 Page Totals 0 0 0 0 0 days 0 days 0 0 0 0 0 0 Be sure to transfer these totals to the Summary (OSHA Form 300A) before you post it * Using “1” instead of an “x” allows the columns to total automatically. Injury Skin disorder Respiratory condition Poisoning Hearing Loss All other illnesses Page       of       (1) (2) (3) (4) (5) (6) 1 OSHA Form 300A Summary of Work-Related Injuries and Illnesses Year 20       All covered establishments must complete this Summary, 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, write the totals below, make sure you've added the entries from every page of the Log . If you haven't had any cases, write "0". Employees, former employees, and their representatives, have the right to review the OSHA Form 300 in its entirety. Establishment Information Your establishment name       Street       City       State       ZIP       Industry description (e.g., Manufacturer of motor truck trailers)       Standard Industrial Classification (NAICS), if known (e.g.,336212)                         Employment Information (If you don’t have these figures, see the worksheet on the back of this page to estimate.) Annual average number of employees       Total hours worked by all employees last year       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:    /    /      Number of Cases 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                         (G) (H) (I) (J) Number of Days Total number of days away from work Total number of days of job transfer or restriction             (K) (L) Injury and Illness Types Total number of… (M) (1) Injuries       (4) Poisonings       (2) Skin disorders       (5) Hearing Loss       (3) Respiratory conditions       (6) All other illnesses       Keep this Summary posted from February 1 to April 30 of the year following the year covered by this form.