OSHA 300, 301, 300A Forms
Comments
 Share
The version of the browser you are using is no longer supported. Please upgrade to a supported browser.Dismiss

 
$
%
123
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Still loading...
ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
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.
2
3
OSHA's Form 300 (Rev. 01/2004)Year2014
4
Log of Work-Related Injuries and IllnessesU.S. Department of Labor
5
Occupational Safety and Health Administration
7
8
9
You must record information 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. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must complete an injury and illness incident report (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you're not sure whether a case is recordable, call your local OSHA office for help.Form approved OMB no. 1218-0176
10
11
Establishment nameConstruction Ahead, Inc. dba Pavement Surface Control
12
CityKennewickStateWA
13
14
Identify the personDescribe the caseClassify the case
15
CHECK ONLY ONE box for each case based on the most serious outcome for that case:Enter the number of days the injured or ill worker was:Check the "injury" column or choose one type of illness:
16
(A)(B)(C)(D)(E)(F)
17
Case No.Employee's NameJob Title (e.g., Welder)Date of injury or onset of illnessWhere the event occurred (e.g. Loading dock north end)Describe injury or illness, parts of body affected, and object/substance that directly injured or made person ill (e.g. Second degree burns on right forearm from acetylene torch)
18
19
(M)Skin DisorderRespiratory ConditionPoisoningHearing LossAll other illnesses
20
DeathDays away from workRemained at workAway From Work (days)On job transfer or restriction (days)Injury
21
(mo./day)
22
Job transfer or restrictionOther record- able cases
23
24
(G)(H)(I)(J)(K)(L)(1)(2)(3)(4)(5)(6)
25
9322
26
1664Chiloe ChervenellFlagger@I-82 EastContusion to right foot from sign dropping on footx2x
27
28
29
30
31
32
33
34
35
36
37
38
Page totals 010020100000
39
40
Be sure to transfer these totals to the Summary page (Form 300A) before you post it.InjurySkin DisorderRespiratory ConditionPoisoningHearing LossAll other illnesses
41
42
Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review the instruction, 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 aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Ave, NW, Washington, DC 20210. Do not send the completed forms to this office.
43
44
45
46
Page1 of 1(1)(2)(3)(4)(5)(6)
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
Loading...
 
 
 
OSHA Form 300
OSHA Form 300A
OSHA Form 301