OSHA’s Form 300 (Rev.
04/2004) Note: You can type input into this form and save it. Attention: This form contains information relating to
Log of Work-Related
Because the forms in this recordkeeping package are “fillable/writable” employee health and must be used in a manner that
PDF documents, you can type into the input form fields and protects the confidentiality of employees to the extent Year 20
then save your inputs using the free Adobe PDF Reader. In addition, possible while the information is being used for
Injuries and Illnesses the forms are programmed to auto-calculate as appropriate. occupational safety and health purposes.
U.S. Department of Labor
Occupational Safety and Health Administration
Please Record: Reminders: Form approved OMB no. 1218-0176
• Information about every work-related death and about every work-related injury or illness that involves loss of • Complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent
consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. form for each injury or illness recorded on this form. If you're not sure whether a Establishment name
• Significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. case is recordable, call your local OSHA office for help.
• Work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 • Feel free to use two lines for a single case if you need to.
• Complete the 5 steps for each case. City State
through 1904.12.
Step 1. Identify the person Step 2. Describe the case Step 3. Classify the case Step 4. Step 5.
SELECT ONLY ONE circle based on the
(A) (B) (C) (D) (E) (F) most serious outcome: Enter the number of
days the injured or ill Select one column:
Case Employee’s name Job title Date of injury Where the event occurred Describe injury or illness, parts of body worker was:
no. (e.g., Welder) or onset of (e.g., Loading dock north end) affected, and object/substance that
illness directly injured or made person ill (e.g., Remained at Work
Illness
(e.g., 2/10) Second degree burns on right forearm from
acetylene torch) Days away Job transfer Other record- Away On job (M)
Skin disorder
Hearing loss
Death from work or restriction able cases from transfer or
Respiratory
Poisoning
restriction
All other
condition
work
illnesses
(G) (H) (I) (J)
Injury
(K) (L)
(1) (2) (3) (4) (5) (6)
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month / day days days
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month / day days days
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month / day days days
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month / day days days
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month / day days days
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month / day days days
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month / day days days
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month / day days days
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month / day days days
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month / day days days
▼
Public reporting burden for this collection of information is estimated to average 14 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
Page totals 0 0 0 0 0 0 0 0 0 0 0 0
respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these Add a
Add a Form
Form Page
Page
Skin disorder
Be sure to transfer these totals to the Summary page (Form 300A) before you post it.
Injury
condition
Hearing loss
Respiratory
All other
illnesses
Poisoning
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.
(1) (2) (3) (4) (5) (6)
OSHA’s Form 300A (Rev. 04/2004) Note: You can type input into this form and save it.
Because the forms in this recordkeeping package are “fillable/writable” Year 20
PDF documents, you can type into the input form fields and
Summary of Work-Related Injuries and Illnesses then save your inputs using the free Adobe PDF Reader. 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.” Establishment information
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 Your establishment name
these forms.
Street
Number of Cases
City State Zip
Total number of Total number of Total number of cases Total number of
deaths cases with days with job transfer or other recordable Industry description (e.g., Manufacture of motor truck trailers)
away from work restriction cases
0 0 0 0
(G) (H) (I) (J) North American Industrial Classification (NAICS), if known (e.g., 336212)
Number of Days
Employment information (If you don't have these figures, see the
Total number of days Total number of days of Worksheet on the next page to estimate.)
away from work job transfer or restriction
Annual average number of employees
0 0
Total hours worked by all employees last year
(K) (L)
Sign here
Injury and Illness Types Knowingly falsifying this document may result in a fine.
Total number of . . . I certify that I have examined this document and that to the best of
(M)
my knowledge the entries are true, accurate, and complete.
(1) Injuries 0 (4) Poisonings 0
(2) Skin disorders 0 (5) Hearing loss Company executive Title
0
Phone Date
(3) Respiratory conditions 0 (6) All other illnesses 0
Post this Summary page from February 1 to April 30 of the year following the year covered by the form. Reset
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 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.
