OSHA 300A Summary of Work-Related Injuries and Ilnesses

OSHA’s Form 300A (Rev. 01/2004)

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.

Establishment information
Your establishment name

__________________________________________

Street

_____________________________________________________

City

____________________________ State ______ ZIP _________

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)

Industry description (e.g., Manufacture of motor truck trailers)
_______________________________________________________
Standard Industrial Classification (SIC), if known (e.g., 3715)
____ ____ ____ ____
OR

(J)

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

___________

___________

(K)

(L)

Employment information (If you don’t have these figures, see the
Worksheet on the back of this page to estimate.)

Injury and Illness Types

Annual average number of employees

______________

Total hours worked by all employees last year

______________

Sign here
Knowingly falsifying this document may result in a fine.

Total number of . . .
(M)
(1)

Injuries

______

(2)

Skin disorders

______

(3)

Respiratory conditions

______

(4)

Poisonings

______

(5)

Hearing loss

______

(6)

All other illnesses

______

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

Post this Summary page from February 1 to April 30 of the year following the year covered by the form.
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.