Form and Instructions for Recording Work-Related Injuries and Illnesses

Recording Work-Related Injuries and Illnesses, Forms 300, 300A, and 301

OSHA Forms for Recording Work-Related Injuries and Illnesses

This booklet includes the forms needed for maintaining occupational injury and illness records. Many but not all employers must complete the OSHA injury and illness recordkeeping forms on an ongoing basis.

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Forms for Recording

Work-Related

Injuries and Illnesses

What's Inside ...
In this package, you'll find everything you need to complete
OSHA's Log and the Summary of Work-Related lrifuries and Illnesses
for the next several years. On the following pages, you'll find:
T An Overview: Recording Work-Related

Dear Employer:
This booklet includes the forms needed for maintaining occupational injury and
illness records. Many but not all employers must complete the OSHA injury and
illness recordkeeping forms on an ongoing basis. Employers in State Plan States
should check with their State Plan to see if the exemptions below apply.
Employers with 10 or fewer employees throughout the previous calendar year
do not need to complete these forms. In addition to the small employer exemption,
there is an exemption for establishments classified in certain industries. A
complete list of exempt industries can be found on the OSHA web page at https://
www.osha.gov/recordkeeping.
Establishments normally exempt from keeping the OSHA forms must complete
the forms if they are informed in writing to do so by the Bureau of Labor Statistics
or OSHA.
All employers, including those partially exempted by reason of company size
or industry classification, must report to OSHA any workplace incident that results
in a fatality, in-patient hospitalization, amputation, or loss of an eye. You can
report to OSHA by calling OSHA's free and confidential number at 1-800-321OSHA (6742); calling your closest Area Office during normal business hours; or
by using the online reporting form at https://www.osha.gov/pls/ser/serform.html.
Starting in 2017, many employers will be required to electronically submit their
injuries and illnesses records to OSHA. To see if your establishment is required to
submit the information, visit https://www.osha.gov/recordkeeping/finalrule/.
The Occupational Safety and Health Administration shares with you the goal
of preventing injuries and illnesses in our nation's workplaces. Accurate injury and
illness records will help us achieve that goal.
Occupational Safety and Health Administration
U.S. Department of Labor

Injuries and Illnesses -

General instructions for filling out the forms in this package and
definitions of terms you should use when you classify your cases as
injuries or illnesses.

T How to Fill Out the Log - An example to guide you in filling out
the Log properly.

T Log of Work-Related Injuries and
Illnesses-A
copy of the Log (but you
may make as many copies of the Log as
you need.) Notice that the Log is
separate from the Summary.
T Summary of Work-Related Injuries
and Illnesses - Removable Summary
pages for easy posting at the end of the
year. Note that you post the Summary
only, not the Log.
T Worksheet to Help You Fill Out the Summary - A worksheet for
figuring the average number of employees who worked for your
establishment and the total number of hours worked.
T OSHA's 301: Injury and Illness
Incident Report - A copy of the OSHA
301 to provide details about the incident.
You may make as many copies as you
need or use an equivalent form.
Take a few minutes to review this package. If you have any questions,
visit us online at www.osha.gov

We'll be happy to help you.

or call your local OSHA office.

An OvervielN:
Recording Work-Related

What do you need to do?

Injuries and Illnesses

1. Within 7 calendar days after you receive
information about a case, decide if the
case is recordable under the OSHA
recordkeeping requirements.

The Occupational Safety and Health (OSH) Act of 1970 requires certain employers to prepare and maintain records of work-related injuries and illnesses. Use these
definitions when you classify cases on the Log. OSHA’s recordkeeping regulation (see 29 CFR Part 1904) provides more information about the definitions below.

The Log of Work-Related l,yuries and Illnesses
(Form 300) is used to classify work-related
injuries and illnesses and to note the extent and
severity of each case. When an incident occurs,
use the Log to record specific details about what
happened and how it happened. The Summary a separate form (Form 300A)- shows the totals
for the year in each category. At the end of the
year, post the Summary in a visible location so
that your employees are aware of the injuries and
illnesses occurring in their workplace.
Employers must keep a Log for each
establishment or site. If you have more than one
establishment, you must keep a separate Log and
Summary for each physical location that is
expected to be in operation for one year or
longer.
Note that your employees have the right to
review your injury and illness records. For more
information, see 29 Code of Federal Regulations
Part 1904.35, Employee Involvement.
Cases listed on the Log of Work-Related
l,yuries and Illnesses are not necessarily eligible
for workers' compensation or other insurance
benefits. Listing a case on the Log does not mean
that the employer or worker was at fault or that
an OSHA standard was violated.
When is an injury or illness considered
work-related?

An injury or illness is considered workrelated if an event or exposure in the work
environment caused or contributed to the
condition or significantly aggravated a
preexisting condition. Work-relatedness is

presumed for injuries and illnesses resulting
from events or exposures occurring in the
workplace, unless an exception specifically
applies. See 29 CFR Part 1904.5(b )(2) for the
exceptions. The work environment includes the
establishment and other locations where one or
more employees are working or are present as a
condition of their employment. See 29 CFR Part
1904.5(b)(l).

Which work-related injuries and
illnesses should you record?
Record those work-related injuries and illnesses
that result in:
T death,

T
T
T
T

loss of consciousness,
days away from work,
restricted work activity or job transfer, or
medical treatment beyond first aid.
You must also record work-related injuries
and illnesses that are significant (as defined
below) or meet any of the additional criteria
listed below.
You must record any significant workrelated injury or illness that is diagnosed by a
physician or other licensed health care
professional. You must record any work-related
case involving cancer, chronic irreversible
disease, a fractured or cracked bone, or a
punctured eardrum. See 29 CFR 1904.7.

What are the additional

2. Determine whether the incident is a new

criteria?

case or a recurrence of an existing one.

You must record the following conditions when
they are work-related:

3. Establish whether the case was work-

T any needlestick injury or cut from a sharp

4. If the case is recordable, decide which
form you will fill out as the injury and
illness incident report.
You may use OSHA 's 301: l,yury
and Illness Incident Report or an
equivalent form. Some state workers
compensation, insurance, or other reports
may be acceptable substitutes, as long as
they provide the same information as the
OSHA 301.

object that is contaminated with another
person's blood or other potentially
infectious material;

T any case requiring an employee to be
medically removed under the requirements
of an OSHA health standard;

T tuberculosis infection as evidenced by a
positive skin test or diagnosis by a physician
or other licensed health care professional
after exposure to a known case of active
tuberculosis;

Tan employee's hearing test (audiogram)
reveals 1) that the employee has experienced
a Standard Threshold Shift (STS) in hearing
in one or both ears (averaged at 2000, 3000,
and 4000 Hz) and 2) the employee's total
hearing level is 25 decibels (dB) or more
above audiometric zero ( also averaged at
2000, 3000, and 4000 Hz) in the same ear(s)
as the STS.

What is medical treatment?
Medical treatment includes managing and
caring for a patient for the purpose of
combating disease or disorder. The following
are not considered medical treatments and are
NOT recordable:

T visits to a doctor or health care professional
solely for observation or counseling;

related.

How to work with the Log

1. Identify the employee involved unless it is
a privacy concern case as described
below.

2. Identify when and where the case
occurred. Also describe the case, as
specifically as you can.

3. Classify the seriousness of the case by
recording the most serious outcome
associated with the case, with column G
(Death) being the most serious and
column J (Other recordable cases) being
the least serious.

4. Enter the number of days the injured or ill
worker was away from work or was on
job transfer or restricted work activity.

5. Identify whether the case is an injury or
illness. If the case is an injury, check the
injury category. If the case is an illness,
check the appropriate illness category.

T diagnostic procedures, including administering
prescription medications that are used solely for
diagnostic purposes; and
T any procedure that can be labeled first aid. (See
below for more i,iformation about first aid.)

If the incident required only the following types of
treatment, consider it first aid. Do NOT record the
case if it involves only:
T using non-prescription medications at nonprescription strength;
T administering tetanus immunizations;
T cleaning, flushing, or soaking wounds on the
skin surface;
T using wound coverings, such as bandages,
BandAids™, gauze pads, etc., or using
SteriStrips™ or butterfly bandages;
T using hot or cold therapy;
T using any totally non-rigid means of support,
such as elastic bandages, wraps, non-rigid back
belts, etc.;
T using temporary immobilization devices while
transporting an accident victim (splints, slings,
neck collars, or back boards);
T drilling a fingernail or toenail to relieve
pressure, or draining fluids from blisters;
T using eye patches;
T using simple irrigation or a cotton swab to
remove foreign bodies not embedded in or
adhered to the eye;
T using irrigation, tweezers, cotton swab or other
simple means to remove splinters or foreign
material from areas other than the eye;

T using finger guards;
T using massages;
T drinking fluids to relieve heat stress.
How do you decide if the case
involved restricted work?
Restricted work activity occurs when, as the result
of a work-related injury or illness, an employer or
health care professional keeps, or recommends
keeping, an employee from doing the routine
functions of his or her job or from working the
full workday that the employee would have been
scheduled to work before the injury or illness
occurred.

How do you count the number of
days of restricted work activity or
the number of days away from work?
Count the number of calendar days the employee
was on restricted work activity or was away from
work as a result of the recordable injury or illness.
Do not count the day on which the injury or
illness occurred in this number. Begin counting
days from the day after the incident occurs. If a
single injury or illness involved both days away
from work and days of restricted work activity,
enter the total number of days for each. You may
stop counting days of restricted work activity or
days away from work once the total of either or
the combination of both reaches 180 days.

Under what circumstances should
you NOT enter the employee's name
on the OSHA Form 300?

injury or illness, but you do not need to include
details of an intimate or private nature.

You must consider the following types of injuries
or illnesses to be privacy concern cases:

What if the outcome changes after
you record the case?

T an injury or illness to an intimate body part or

If the outcome or extent of an injury or illness
changes after you have recorded the case,
simply draw a line through the original entry or,
if you wish, delete or white-out the original
entry. Then write the new entry where it
belongs. Remember, you need to record the
most serious outcome for each case.

to the reproductive system,

T an injury or illness resulting from a sexual
assault,

T a mental illness,
T a case of HIV infection, hepatitis, or
tuberculosis,

T a needlestick injury or cut from a sharp object
that is contaminated with blood or other
potentially infectious material (see 29 CFR Part
1904.8 for definition), and

T other illnesses, if the employee independently
and voluntarily requests that his or her name
not be entered on the log.
You must not enter the employee's name on the
OSHA 300 Log for these cases. Instead, enter
"privacy case" in the space normally used for the
employee's name. You must keep a separate,
confidential list of the case numbers and employee
names for the establishment's privacy concern
cases so that you can update the cases and provide
information to the government if asked to do so.
If you have a reasonable basis to believe that
information describing the privacy concern case
may be personally identifiable even though the
employee's name has been omitted, you may use
discretion in describing the injury or illness on
both the OSHA 300 and 301 forms. You must
enter enough information to identify the cause of
the incident and the general severity of the

Classifying

injuries

An injury is any wound or damage to the body
resulting from an event in the work
environment.
Examples: Cut, puncture, laceration,
abrasion, fracture, bruise, contusion, chipped
tooth, amputation, insect bite, electrocution, or
a thermal, chemical, electrical, or radiation
bum. Sprain and strain injuries to muscles,
joints, and connective tissues are classified as
injuries when they result from a slip, trip, fall or
other similar accidents.

Classifying illnesses
Skin diseases or disorders
Skin diseases or disorders are illnesses involving
the worker's skin that are caused by work
exposure to chemicals, plants, or other
substances.
Examples: Contact dermatitis, eczema, or
rash caused by primary irritants and sensitizers
or poisonous plants; oil acne; friction blisters,
chrome ulcers; inflammation of the skin.

Respiratory conditions
Respiratory conditions are illnesses associated
with breathing hazardous biological agents,
chemicals, dust, gases, vapors, or fumes at work.
Examples: Silicosis, asbestosis, pneumonitis,
pharyngitis, rhinitis or acute congestion;
farmer's lung, beryllium disease, tuberculosis,
occupational asthma, reactive airways
dysfunction syndrome (RADS), chronic
obstructive pulmonary disease (COPD),
hypersensitivity pneumonitis, toxic inhalation
injury, such as metal fume fever, chronic
obstructive bronchitis, and other
pneumoconioses.

Poisoning
Poisoning includes disorders evidenced by
abnormal concentrations of toxic substances in
blood, other tissues, other bodily fluids, or the
breath that are caused by the ingestion or
absorption of toxic substances into the body.

Examples: Poisoning by lead, mercury,
cadmium, arsenic, or other metals; poisoning by
carbon monoxide, hydrogen sulfide, or other
gases; poisoning by benzene, benzol, carbon
tetrachloride, or other organic solvents;
poisoning by insecticide sprays, such as
parathion or lead arsenate; poisoning by other
chemicals, such as formaldehyde.

Hearing Loss
Noise-induced hearing loss is defined for
recordkeeping purposes as a change in hearing
threshold relative to the baseline audiogram of an
average of 10 dB or more in either ear at 2000,
3000 and 4000 hertz, and the employee's total
hearing level is 25 decibels (dB) or more above
audiometric zero (also averaged at 2000, 3000,
and 4000 hertz) in the same ear(s).

All other illnesses
All other occupational illnesses.
Examples: Heatstroke, sunstroke, heat
exhaustion, heat stress and other effects of
environmental heat; freezing, frostbite, and other
effects of exposure to low temperatures;
decompression sickness; effects of ionizing
radiation (isotopes, x-rays, radium); effects of
nonionizing radiation (welding flash, ultra-violet
rays, lasers); anthrax; blood borne pathogenic
diseases, such as AIDS, HIV, hepatitis B or
hepatitis C; brucellosis; malignant or benign
tumors; histoplasmosis; coccidioidomycosis.

When must you post the Summary?
You must post the Summary only - not the
Log - by February 1 of the year following the
year covered by the form and keep it posted
until April 30 of that year.

How long must you keep the Log
and Summary on file?
You must keep the Log and Summary for 5 years
following the year to which they pertain.

Do you have to send these forms
to OSHA at the end of the year?
Starting in 2017, many employers will be required
to electronically submit their injuries and illnesses
records to OSHA. To see if your establishment is
required to submit the information, visit https://
www.osha.gov/recordkeeping/finalrule/.

How can we help you?
If you have a question about how to
fill out the Log,
T visit us online at www.osha.gov
T call your local OSHA office.

Optional

Calculating

Injury and Illness Incidence

What is an incidence rate?
An incidence rate is the number of recordable
injuries and illnesses occurring among a given
number of full-time workers (usually 100 fulltime workers) over a given period of time
(usually one year). To evaluate your firm's injury
and illness experience over time or to compare
your firm's experience with that of your industry
as a whole, you need to compute your incidence
rate. Because a specific number of workers and a
specific period of time are involved, these rates
can help you identify problems in your workplace
and/or progress you may have made in preventing
work-related injuries and illnesses.

How do you calculate
rate?

an incidence

You can compute an occupational injury and
illness incidence rate for all recordable cases or
for cases that involved days away from work for
your firm quickly and easily. The formula
requires that you follow instructions in paragraph
(a) below for the total recordable cases or those in
paragraph (b) for cases that involved days away
from work, and for both rates the instructions in
paragraph ( c).
(a) To find out the total number of recordable
injuries and illnesses that occurred during the
year, count the number ofline entries on your
OSHA Form 300, or refer to the OSHA Form
300A and sum the entries for columns (G), (H),
(I), and (J).
(b) To find out the number oftnjuries and
illnesses that involved days away from work,
count the number of line entries on your OSHA
Form 300 that received a check mark in column
(H), or refer to the entry for column (H) on the
OSHA Form 300A.

(c) The number of hours all employees actually
worked during the year. Refer to OSHA Form
300A and optional worksheet to calculate this
number.
You can compute the incidence rate for all
recordable cases of injuries and illnesses using the
following formula:
Total number of injuries and illnesses X 200,000 +
Number of hours worked by all employees= Total
recordable case rate
(The 200,000 figure in the formula represents the
number of hours 100 employees working 40 hours
per week, 50 weeks per year would work, and
provides the standard base for calculating
incidence rates.)
You can compute the incidence rate for
recordable cases involving days away from work,
days of restricted work activity or job transfer
(DART) using the following formula:

Rates

Note: You can type input into this form and save it.
Because the forms in this recordkeeping package are “fillable/writable”
PDF documents, you can type into the input form fields and
then save your inputs using the free Adobe PDF Reader. In addition,
the forms are programmed to auto-calculate as appropriate.

various classifications (e.g., by industry, by
employer size, etc.). You can obtain these
published data at www.bls.gov/iif or by calling
a BLS Regional Office.

Worksheet

Total number of
injuries and illnesses

X 200,000

(Number of entries in column H + Number of
entries in column I) X 200,000 + Number of hours
worked by all employees = DART incidence rate
You can use the same formula to calculate
incidence rates for other variables such as cases
involving restricted work activity (column (I) on
Form 300A), cases involving skin disorders
(column (M-2) on Form 300A), etc. Just substitute
the appropriate total for these cases, from Form
300A, into the formula in place of the total number
of injuries and illnesses.

What can I compare my incidence
rate to?
The Bureau of Labor Statistics (BLS) conducts a
survey of occupational injuries and illnesses each
year and publishes incidence rate data by

Number of entries in
Column H + Column I

X 200,000

Number of
hours worked
by all employees

Total recordable
case rate

Number of
hours worked
by all employees

DART incidence
rate

Because the forms in this recordkeeping package are “fillable/
writable” PDF documents, you can type into the input form fields and
then save your inputs using the free Adobe PDF Reader. In addition,
the forms are programmed to auto-calculate as appropriate.

HoVII to Fill Out the Log
The Log of Work-Related Injuries and
Illnesses is used to classify work-related
injuries and illnesses and to note the
extent and severity of each case. When an
incident occurs, use the Log to record
specific details about what happened and
how it happened.
If your company has more than one
establishment or site, you must keep
separate records for each physical location
that is expected to remain in operation for
one year or longer.
If you need additional copies of the
Log, you may photocopy the printout or
insert additional form pages in the PDF,
and then use as many as you need.
The Summary - a separate form shows the work-related injury and illness
totals for the year in each category. At the
end of the year, count the number of
incidents in each category and transfer the
totals from the Log to the Summary. Then
post the Summary in a visible location so
that your employees are aware of injuries
and illnesses occurring in their workplace.
You don't post the Log. You post
only the Summary at the end of the

year.

OSHA 's Form 300

Note: You can type input into this form and save it.

Log of Work-Related
Injuries and Illnesses

Because the forms in this recordkeeping package are "fillable/writable"
PDF documents, you can type into the input form fields and
then save your inputs using the free Adobe PDF Reader. In addition,
the forms are programmed to auto-calculate as appropriate.

Please Record:

~~i~o~:~?~~~t~t~n

g~~t~g\~
ei~g~~~eis~dt~;r
occupational safety and health purposes.

death and about every work-related injury or illness that involves loss of

consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid.
• Significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional.
• ~~~~;~'~:~'.~jiries

and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.B

Step 1 Jdent,fy the person

(B)
EmJlloyee'sname

(D)
Date of injury
oronsc1of
illness
(e.g.. 2110)

• Complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent
form for each injury or illness recorded on th!s form. If you're not sure whether a Establishment name

case is recordable, call your local OSHA office for help.
: 6~~;,:~et~h~s; :;:~~:

(E)
Whcrethecvcntoccurred

mm...!_
mm
mm
mm
mm
mm____
mm____

City

Step3 C/ass,fythecase

(F)
Dcscribcinjuryorillncss,partsofbody

Job1ransferor
restriction

state

•

Welder

~ Shana Alexander

F 011nd1J'man

Electrician

~Sa="'~S=a"=de~"----

5 125
month/~

7 12
month/~

815
monthlaay-

9117

Ra/pl, Boccella

month/aay-

Machine op1:

_J__ Jarrod Daniels

_
_

JO I 23
month/~

basement

fracture, left ann and left leg,fe/1 J,-0111 ladder

pouring deck

poiso11il1gfrom leadfi,mes

2nd floor storeroom

broke11/eg,fe/1 over box

packaging depanmem

back strain lifting a box

prod11ctio11jloor

1e ________
_du_st_in_le~ifi~e)_

0
0
0
0

(M)

Otherrecord-able
cases

(H)

(I)

(J)

0
0

I
month/aay-

0
0
0

(K)

_!_}__days __!J___days

days

__}_days

-,aay-

0
0

_days

Illness

ilJtIIU

(L)

~""t-,,-_,11119!"""'"-____l_days

0
0
0

,M!1_____

Enterrhenumberofdaysthe
injuredorillworkerwos:

SELECTONLYONEcrc/ebasedon/hemosrser1ovs

(e.g .. Loading dock north end) 11ffee1ed,and objcct/subslancc lhat
ill(e.g.,
dircctlyinjurcdormadepcrson
Seco11ddegree bums 011righ1forearmfrom
acery/enetorch)

XYZ con1panv

Anvw here

(1)

_At_a,_·k_Ba~g~i11
____

of Labor

---~~------

;o;c~ ~;;~~ case if you need to.

(G)

mmJ_

U.S. Department

Occupationa/SafetyondHealthAdministration

Fonnapproved 0MB no. 1218-0176

Step 2 Descnbe the case

(e.g .. Welder)

_j_

Year 20

extent

Reminders:

• Information about every work-related

(A)
Case

Attention: This form contains information relating to
employee health and must be used in a manner that

___}_!!_days

(~)

(3)

(4)

(5)

_}_Q_oays

_days

days

_days_days

V
Be as specific as possible. You
can use two lines if you need
more room.
Revise the log if the injury or illness
progresses and the outcome is more serious
than you originally recorded for the case.
Cross out, erase, or white-out the original
entry if hard copy. (If using the PDF's fillable
form feature, simply change your selections.
You can also clear the entire case entry from
the log using the Reset button.)

Choose ONLY ONE of these
categories. Classify the case
by recording the most
serious outcome of the case,
with column G (Death) being
the most serious and column
J (Other recordable cases)
being the least serious.

(6)

@00000
000@00

Note whether the
case involves an
injury or an illness.

0
0
0
0

OSHA’s Form 300

(Rev. 04/2004)

Log of Work-Related
Injuries and Illnesses~----------~

Please Record:
• Information about everywork-relateddeath and about everywork-relatedinjury or illnessthat involveslossof

consciousness,restrictedworkactivityorjob transfer,days away from work,or medicaltreatment beyond firstaid.
• Significantwork-relatedinjuriesand illnessesthat are diagnosedby a physician or licensedhealth careprofessional.
• Work-relatedinjuriesand illnessesthat meetany of the specificrecordingcriteria listed in 29 CFRPart 1904.8
through 1904.12.

Reset
CJ
Reset
CJ
Reset
c=J
Reset
c=J
Reset
CJ
Reset
CJ
Reset
CJ
Reset
CJ
Reset
CJ
Reset
c=J

(B)
Employee's name

(D)
Date of injury
or onset of
illness
(e.g., 2/10}

Step 4.
Enter the number at
days ffle Injured or

most serious outcome:

Days away
from work

(G)

(H)

/
--month / day
--

Job transfer
or restriction

(I)

r
r
r
r
r
r

r
0 r
r r
r r
r 0
r1 0 0
r 0 r
0 ri r
Q
0 r

/
--month / day
-/

--month / day
-/
--month / day
-/
--month / day
--

--month // day
-/
--month / day
-/
--month / day
--

--month // day
--

instructiorui,searchand gatherthe data ne.eded,and completeand reviewthe collectionof infonnation.Personsare not required to

ill worfcer

Step S.

Other recordable cases

(J)

r
r
r
r
r
0
0

r
r
r

Select

one column:

was:

Illness

Remained at Work

--month // day
--

Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review the

State

City

SELECT OIVL Y OIVE circle based on the

Death

of Labor

Safety and Health Administration

Establishment name

Step 3. Classify the case

directly injured or made person ill (e.g.,
Second degree burns on right forearm from
acetylene torch)

Page totals

U.S. Department
Occupational

Form approved 0MB no. 1218-0176

Reminders:
• Completean Injury and IllnessIncidentReport(OSHAForm 301) or equivalent
form for eachinjury or illnessrecordedon this form.If you're not surewhethera
caseis recordable,call your local OSHAoffice for help.
• Feelfree to usetwo linesfor a single caseif you need to.
• Completethe 5 stepsfor eachcase.

(E)
(F)
Where the event occurred
Describe injury or illness, parts of body
(e.g., Loading dock north end) affected, and object/substance that

respond to the collection of information wtless it displays a currently valid 0MB 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.

Year 20

protects the confidentiality of employees to the extent
possible while the information is being used for
occupational safety and health purposes.

Step 2. Describe the case

Step 1. Identify the person
(A)
Case
no.

This form contains information relating to
IAttanUon,
employee health and must be used in a manner that

(M)

Away

tr!'n'!/:~ or
restriction

from
wark

(K)

(L)

(1)

days

I
.9
Ii Sa
".
r
~~
"'
J H
"'0 1 '" ';1~
(2) (3) (4) (5)
(6)

rorrrr
rrrrrn
rrrrrr
rrrrrr

rrrrrr
rc 1rroo
orrroo

►

Be sure to transfer these totals to the Summary page (Form 300A) before you post it.

Paga __

(1)

(2) (3)

(4)

(5)

(6)

OSHA’s Form 300A

(Rev. 04/2004)

Summary of Work-Related

Injuries and Illnesses

Year 20

Nate: Yau can type input into this form and save it.
Because the forms in this recordkeeping package are “fillable/writable”
PDF documents, you can type into the input form fields and
then save your inputs using the free Adobe PDF Reader.

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

FonnapprovedOMBno.1218-D176

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
Vow establishment

Street

Number of Cases

information
name

------------------------

City ___________
Total number of
deaths

Total number of
cases with days
away from work

Total number of cases
with job transfer or
restriction

(G)

Total number of
other recordable
cases

(H)

State ___

Zip ___

Industry description (e.g., Manufacture of motor truck trailers)

(I)

(J)

North American Industrial Classification(NAICS), if known (e.g., 336212)

IIIIIII
Number of Days

Employment information (If you don't have these figures,

Total number of days
away from work

see

the

Worksheet on the next page to estimate.)

Total number of days of job
transfer or restriction

Annual average number of employees

0
Total hours worked by all employeeslast year

(K)

(L)

Sign here
Injury and Illness

Types

Knowingly falsifying this document may result in a fine.

Total number of.
(M)

(1) Injuries

(4) Poisonings

(2) Skin disorders

(5) Hearing loss

(3) Respiratory conditions

(6) All other illnesses

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 58 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 0MB 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.

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
Phone

Title
Date

Note: Yau can type input into this farm and save it.
Because the forms in this recordkeeping package are “fillable/writable”
PDF documents, you can type into the input form fields and
then save your inputs using the free Adobe PDF Reader. In addition,
the forms are programmed to auto-calculate as appropriate.

Optional

Worksheet

to Help You Fill Out the Summary

At the end of the year, OSHA requires you to enter the average number of employees and the total hours worked by your employees on
the summary. If you don’t have these figures, you can use the information on this page to estimate the numbers you will need to enter on
the Summary page at the end of the year.

Haw to figure the average number of employees
who worked far your establishment during the
year:
•1

•
•
•
2

Haw ta figure the total hours worked by all employees:

Add the total number of employees your

establishment paid in all pay periods during the
year. Include all employees: full-time, part-time,
temporary, seasonal, salaried, and hourly.

The number of employees
paid in all pay periods=

•1
____

Count the number of pay periods your
establishment had during the year. Be sure to
include any pay periods when you had no
employees.

The number of pay
periods during the year =

•

Divide the number of employees by the number of

••

Round the answer to the next highest whole
number. Write the rounded number in the blank
marked Annual average number of employees.

1
2

pay periods.

The number rounded

Include hours worked by salaried, hourly, part-time and seasonal workers, as
well as hours worked by other workers subject to day to day supervision by
your establishment (e.g., temporary help services workers).
Do not include vacation, sick leave, holidays, or any other non-work time,
even if employees were paid for it. If your establishment keeps records of only
the hours paid or if you have employees who are not paid by the hour, please
estimate the hours that the employees actually worked.
If this number isn't available, you can use this optional worksheet to
estimate it.

=•

Optional Worksheet
Find the number of full-time employees in your
establishment for the year .

•
4

This is the number of full-time hours worked.

+
For example, Acme Constructionfigured its average employmentthis way:
In this pay period ... Acme paid this many employees ...

2
3
4
5
T
24
25
26

10
0
15
30
40
T
20
15

Number of employees paid = 830
Number of pay periods = 26
830 = 31.92

26
31.92 rounds to 32

Multiply by the number of work hours for a full-time
employee in a year .

••
•
•

Add the number of any overtime hours as well as the
hours worked by other employees (part-time,
temporary, seasonal)

2
3

32 is the annual average number of employees

Round the answer to the next highest whole number .
Write the rounded number in the blank marked Total
hours worked by all employees last year.

OSHA's Form 301 (Rev. 04/2004)

Injury and Illness
Incident Report
This Injury and Illness Incident Report is one of the
first forms you must fill out when a recordable
work-related injury or illness has occurred. Together
with the Log of Work-Related IY/}uriesand 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 the printout or insert additional form
pages in the PDF, and then use as many as you need.

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.
Information

about the case

10) Case number from the Log

1) Full name

11) Date ofinjury

(J'ransfer the case number from the Log after you record the case.)

or illness

2) Street

Month

Day

Year

12) Time employee began work

3) Date of birth
Month

Month

Male

QPM

O PM

Check if time cannot be determined

1•Re fields 14 to 17: Please do not include any personally identifiable information (PII) pertaining to
Day

worker(s) involved in the incident (e.g., no names, phone numbers, or Social Security numbers).

Year

4) Date hired

QAM

ZIP

State

13) Time of event

.....
__,.. ........
Form approved 0MB no. 1218-0176

Information about the employee

City

-----

Day

14)"' What was the employee doingjust
before the incident accu"ed?
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."

Year

O Female

Information about the physician or other health care
professional
15)"' What Happened?

Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell
20 feet"; "Worker was sprayed with chlorine when gasket broke duriog replacement"; "Worker developed
soreness in wrist over time."

6) Name of physician or other health care professional

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

16)"' What was the injury or illness?

Tell us the part of the body that was affected and how it was affected.
Examples: ''strained back"; ''chemical burn, hand"; ''carpal tunnel syndrome."

Street

City

·z1P

State

or substance
direcUy harmed the employee? Examples: "concrete floor"; "chlorine";
"radial arm saw.'' I/this question does not apply to the incident, leave it blank.

17)"' IVhat abject

8) Was employee treated in an emergency room?

Completed by

Title

Yes

9) Was employee hospitalized overnight as an in-patient?
Phone

Date
Month

Day

Year

0
0

Yes

18)

the employee

died, when did death occur?

Date of death
Month

Day

Year

No
Paga __1

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 maintairung the data needed, and completing and reviewing the collection of infonnation. Persons are not required to respond to the collection of information unless it displays a
current valid 0MB 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.

If You Need Help ...
If you need help deciding whether a case is recordable, or if you have questions about the
information in this package, feel free to contact us. We’ll gladly answer any questions you have.
T Visit us online at www.osha.gov

Federal Jurisdiction

T Call your OSHA Regional office

Region 1 - 617 / 565-9860

and ask for the recordkeeping
coordinator
or

Connecticut;

Massachusetts;

State Plan States

Maine;

New Hampshire; Rhode Island

Alaska - 907 / 269-4957

Oregon - 503 / 378-3272

Arizona - 602 / 542-5795

Puerto Rico - 787 / 754-2172

California - 415 / 703-5100

South Carolina - 803 / 734-9669

New York; New Jersey

*Connecticut - 860 / 566-4380

Tennessee - 615 / 741-2793

Region 3 - 215 / 861-4900

Hawaii - 808 / 586-9100

Utah - 801 / 530-6901

*Illinois - 217 / 782-6206

Vermont - 802 / 828-2765

Alabama; Florida; Georgia; Mississippi

Indiana - 317 / 232-2688

Virginia - 804 / 786-6613

Region 5 - 312 / 353-2220

Iowa- 515 / 281-3661

*Virgin Islands - 340 / 772-1315

Kentucky - 502 / 564-3070

Washington - 360 / 902-4543

Arkansas; Louisiana; Oklahoma; Texas

*Maine - 207 / 623-7900

Wyoming - 307 / 777-7786

Region 7 - 816 / 283-8745

Maryland- 410 / 527-4465

Region 2 - 212 / 337-2378

T Call your State Plan office
DC; Delaware;

Pennsylvania; West Virginia

Region 4 - 678 / 237-0400

Illinois; Ohio; Wisconsin

Region 6 - 972 / 850-4145

Kansas; Missouri; Nebraska

Region 8 - 720 / 264-6550

Michigan - 517 / 322-1848
Minnesota - 651 / 284-5050

Colorado; Montana; North Dakota; South
Dakota

Nevada- 702 / 486-9020

Region 9 - 415 / 625-2547

*New Jersey - 609 / 984-1389

Region 10 - 206 / 553-5930

New Mexico - 505 / 827-4230

Idaho

*New York- 518 / 457-2574
North Carolina- 919 / 807-2875

*Public Sector only

Have questions?
If you need help in filling out the Log or Summary, or if you
have questions about whether a case is recordable, contact
us. We'll be happy to help you. You can:
.., Visit us online at: www.osha.gov
"f Call your regional or state plan office. You'll find the
phone number listed on the previous page.

File Type

application/pdf