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pdfOSHA’s Form 300A (Rev. 01/2011. Previous versions are not to be used.)
Year 20__ __
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 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.
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
__________________
__________________
__________________
__________________
Establishment information
Your establishment name
__________________________________________
Street
_____________________________________________________
City
____________________________ State ______ ZIP _________
Industry description (e.g., Manufacture of motor truck trailers)
_______________________________________________________
Standard Industrial Classification (SIC), if known (e.g., 3715)
(G)
(H)
(I)
____ ____ ____ ____
(J)
OR
North American Industrial Classification (NAICS), if known (e.g., 336212)
Number of Days
____ ____ ____ ____ ____ ____
Total number of days away
from work
Total number of days of job
transfer or restriction
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
______________
(K)
(L)
Total hours worked by all employees last year
______________
Injury and Illness Types
Sign here
Total number of . . .
Knowingly falsifying this document may result in a fine.
(M)
(1)
Injuries
______
(5)
Hearing loss
______
(2)
Skin disorders
______
(6)
Musculoskeletal disorders
______
(7)
All other illnesses
______
(3)
Respiratory conditions
______
(4)
Poisonings
______
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
Post this Summary page from February 1 to April 30 of the year following the year covered by the form.
Paperwork Reduction Act Statement
Public reporting burden for this collection of information is estimated to average 58 minutes per response, including time to review the instructions, search and gather the data needed, and
complete and review the collection of information. Response to this data collection is mandatory pursuant to 29 CFR Part 1904. 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.
Title
(
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/ /
___________________________________________________________
Phone
Date
File Type | application/pdf |
File Title | OSHA_Form_300_complete.cdr |
File Modified | 2010-01-29 |
File Created | 2010-01-29 |