Fillable FORM SH-900.1: SUMMARY OF WORK-RELATED INJURIES AND ILLNESSES (City of New York)

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FORM SH-900.1: SUMMARY OF WORK-RELATED INJURIES AND ILLNESSES (City of New York)

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Divison of Safety and Health
STATE OF NEW YORK
Public Employee Safety and Health
DEPARTMENT OF LABOR
State Office Campus
Building 12, Room 158
Albany, NY 12240
SUMMARY OF WORK-RELATED
Calendar Year
INJURIES AND ILLNESSES
FORM SH-900.1
All establishments covered by PART 801 must complete this summary annually, even if no occupational injuries or illnesses occurred during the
year.
Employees, former employees, and their representatives have the right to review this form. They also have limited access to the Log (SH 900) or its
equivalent. See 801.35 and instructions for further details on access provisions for these forms.
1. ESTABLISHMENT INFORMATION
2. EMPLOYMENT INFORMATION
ESTABLISHMENT NAME
If you don't have accurate figures, see the
instructions on the back of this sheet.
STREET ADDRESS
AVERAGE NUMBER OF EMPLOYEES
CITY, STATE, ZIP CODE
INDUSTRY DESCRIPTION (e.g.,village fire department)
TOTAL HOURS WORKED BY ALL EMPLOYEES LAST YEAR
NORTH AMERICAN INDUSTRIAL CLASSIFICATION SYSTEM (NAICS).
Enter the column totals from the Log of Occupational Injuries and Illnesses (SH 900) for each category (column labels under each
line
correspond to the columns on the Log). If a category has no cases, enter "0."
4. NUMBER OF DAYS 5. INJURIES AND ILLNESS TYPES
3. NUMBER OF CASES
INJURIES
(Col.1)
DEATHS
SKIN DISORDERS
(Col. G)
AWAY FROM
DAYS AWAY (Col. 2)
WORK
FROM WORK
RESPIRATORY CONDITIONS
(Col. K)
(Col. H)
(Col. 3)
JOB TRANSFER
POISONINGS
OR RESTRICTION JOB TRANSFER OR
RESTRICTION
(Col. I)
(Col. 4)
OTHER RECORD- (Col. L)
HEARING LOSS
ABLE CASES
(Col. 5)
(Col. J.)
ALL OTHER ILLNESSES
(Col. 6)
6. CERTIFICATION
I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete.
SIGNATURE
TITLE
PRINT NAME
DATE
SH-900.1 (10-05)
CALCULATING EMPLOYMENT INFORMATION (Section 2)
If accurate figures regarding the average number of employees and the total hours worked by your employees are not
available, please use the steps below to estimate these numbers.
Average Number of Employees
1.
Add the total number of employees paid in all pay periods for the year.
(a)
Include all full-time, part-time, temporary, seasonal, salaried, and hourly
employees.
(b)
2.
Count the number of pay periods for the year, including pay periods
with no employees.
(c)
Divide the number of employees by the number of pay periods.
3.
/
a b
(d)
Round the answer to the next whole number. Enter this number
4.
in the line for "Annual average number of employees" in Item 2 on the front.
Total Hours Worked By All Employees
Enter the number of full-time employees in your establishment
1. (e)
for the year.
(f)
Enter the number of work hours for a full-time employee
2.
in a year.
(g)
x
Multiply (e) by (f) to find the number of full-time hours worked.
3.
(h)
Add number of overtime hours and number of hours worked by
4.
+
other employees (part-time, temporary, seasonal).
5.
Round the answer to the next highest whole number. Enter this
number in the lines for "Total Hours Worked by All Employees
(i)
Last Year" in Item 2 on the front.
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FORM SH-900.1: SUMMARY OF WORK-RELATED INJURIES AND ILLNESSES (City of New York)

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Completed 13 April 2021

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