Department of Indu ts rial Relations
Division of Occupational Safety & Health
Cal/OSHA Form 300A (Rev. 7/2007) Appendix B
Year 20 __
Annual Summary of Work-Related Injuries and Illnesses
Total number of
deaths
__________________
Total number of
cases with days
away from work
__________________
Number of Cases
Total number of days
away from work
___________
Total number of days of job
transfer or restriction
___________
Number of Days
Post this Annual Summary from February 1 t o April 30 of the year following the year covered by the form.
All establishments covered by CCR Title 8 Section 14300 must complete this Annual Summary, 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 Cal/OSHA Form 300 in its entirety. They also have limited access to the Cal/OSHA
Form 301 or its equivalent. See CCR Title 8 Section 14300.35, in Cal/OSHA’s recordkeeping rule, for further details on the access provisions for these forms.
Establishment information
Employment information
Your establishment name _____________________________________________
Street ___ _______ ___ ____ _____ ___________ ___ __________________________
City ________________________________________ State ______ ZIP _________
Industry description (e.g., Manufacture of motor truck trailers )
_______________________________________________________
Standard Industrial Classification (SIC), if known (e.g., SIC 3715 )
____ ____ ____ ____
Annual average number of employees ______________
Total
hours worked by
all employees last year ______________
(If you don’t have these figures, use the optional
Worksheet to estimate.)
Sign here
Knowingly falsifying this document may result in a fine.
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 Title
Phone Date
ga
Total number of . . .
Skin disorders ______
Respiratory conditions ______
Injuries
______
Injury and Illness Types
Poisonings ______
Hearing loss
______
(G)
(H) (I) (J)
(K) (L)
(M)
(1)
(2)
(3)
(4)
(5)
Total number of
cases with job
transfer or restriction
__________________
Total number of
other recordable
cases
__________________
(6)All other Illnesses _____
______________________________________________
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signature
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