OSHA Form 301 Injury and Illness Incident Report

OSHA’s Form 301

Injury and Illness Incident Report

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.

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

Form approved OMB no. 1218-0176

Information about the employee

This Injury and Illness Incident Report is one of the
first forms you must fill out when a recordable workrelated injury or illness has occurred. Together with
the Log of Work-Related Injuries and Illnesses and the
accompanying Summary, 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.

1) Full name _____________________________________________________________
2) Street ________________________________________________________________
City ______________________________________ State _________ ZIP ___________
3) Date of birth ______ / _____ / ______
4) Date hired ______ / _____ / ______
5)

r
r

Information about the case
10) Case number from the Log

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

11) Date of injury or illness

______ / _____ / ______

12) Time employee began work ____________________ AM / PM
13) Time of event

____________________ AM / PM

0 Check if time cannot be determined

14) 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. Be specific. Examples: “climbing a ladder while
carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.”

Male
Female

15) What happened? Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, worker

Information about the physician or other health care
professional
6)

fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker
developed soreness in wrist over time.”

Name of physician or other health care professional __________________________
________________________________________________________________________

7) If treatment was given away from the worksite, where was it given?
Facility _________________________________________________________________
Street

16) What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be

more specific than “hurt,” “pain,” or sore.” Examples: “strained back”; “chemical burn, hand”; “carpal
tunnel syndrome.”

_______________________________________________________________

City ______________________________________ State _________ ZIP ___________
8)

r
r

Completed by _______________________________________________________
Title _________________________________________________________________
Phone (________)_________--_____________

Date

_____/ _____
_
/ _____

17) What object or substance directly harmed the employee? Examples: “concrete floor”; “chlorine”;
Was employee treated in an emergency room?

9)

“radial arm saw.” If this question does not apply to the incident, leave it blank.

Yes
No

Was employee hospitalized overnight as an in-patient?

r
r

Yes
No

18) If the employee died, when did death occur? Date of death ______ / _____ / ______

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.