PLEASE COMPLETE FOR JULY 1, 2019 - DECEMBER 31, 2019.
The time has arrived to submit your JULY 1-DECEMBER 31, 2019 Safety Council (Second Half) Semi-Annual Report. Please take a few moments and complete your Semi-Annual Safety Council report. It is absolutely critical that you return your report by no later than JAN 15th so that we can ensure that you receive your Safety Council rebate and qualify for the annual safety awards.. Please contact portagesafetycouncil@gmail.com or 330-474-3161 with any questions.
BUSINESS INFORMATION
Company *
Phone *
Address *
City *
State *
Zip *
Fax
Submitted by *
E-Mail *
Has information provided above been updated on this report? *
This questions refers to above information (business name, location, etc.). Most will answer "No".
SAFETY REPORT PART 1
1. DATE OF MOST RECENT INJURY OR ILLNESS RESULTING IN DAY(S) AWAY FROM WORK *
This is the date of the most recent injury that resulted in an employee missing at least one FULL day of work. The date does not necessarily have to be during this reporting period but it cannot be after it. If no injuries have ever occurred, please enter 12/31 of the year prior to your company's first year in business. For example, if your company was started in the year 2005, you would enter 12/31/2004.
MM
/
DD
/
YYYY
SAFETY REPORT PART 2
Report All Information Below For CURRENT SIX MONTH PERIOD ONLY: JULY 1, 2019 - DECEMBER 31, 2019.
2. AVERAGE NUMBER OF EMPLOYEES *
3. TOTAL HOURS WORKED *
(ENTIRE SIX MONTH PERIOD, ALL EMPLOYEES)
SAFETY REPORT PART 3
THE FOLLOWING ARE BASED ON THE RECORDKEEPING REQUIREMENTS UNDER THE OCCUPATIONAL SAFETY & HEALTH ACT OF 1970 (REV. 1/1/2002). THE QUESTIONS LISTED BELOW CORRESPOND TO THE COLUMNS IN THE OSHA 300 LOG AND PERRP FORM 300P.
4. NUMBER OF DEATHS *
(COLUMN G IN OSHA 300 LOG/PERRP FORM 300P)
5. NUMBER OF OCCUPATIONAL INJURIES AND/OR ILLNESSES RESULTING IN DAYS AWAY FROM WORK *
(COLUMN H IN OSHA 300 LOG/PERRP FORM 300P) ***QUICK TIP*** If the date in question 1 is within the current reporting period (July 1, 2019 - Dec. 31, 2019) then this question (#5) CAN NOT be "0."
6. NUMBER OF DAYS AWAY FROM WORK AS A RESULT OF OCCUPATIONAL INJURIES AND/OR ILLNESSES *
(COLUMN K IN OSHA 300 LOG/PERRP FORM 300P) ***QUICK TIP*** If the date in question 1 is within the current reporting period (July 1, 2019 - Dec 31, 2019) then this question (#6) CAN NOT be "0."
PLEASE NOTE
IF YOU REPORT A DEATH, INJURY OR ILLNESS RESULTING IN DAYS AWAY FROM WORK IN THE CURRENT SIX MONTH PERIOD IT MUST CORRESPOND TO THE MOST RECENT DATE OF DEATH, INJURY OR ILLNESS NOTED ABOVE
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy