Cal/OSHA Form 301 Appendix C
Injury and Illness Incident Report
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.
See CCR Title 8 14300.29(b)(6)-(10)
Department of Industrial Relations
Division of Occupational Safety & Health
This Injury and Illness Incident Report is one of the
first forms you must fill out when a recordable work-
related injury or illness has occurred. Together with
Log of Work-Related Injuries and Illnesses and the
accompanying Annual Summary, these forms help the
employer and Cal/OSHA develop a picture of the
extent and severity of work-related incidents.
Within 7 calendar days after you receive
information that a recordable work-related injury or
illness has occurred, you must fill out this form or an
equivalent. Some state workers’ compensation,
insurance, or other reports may be acceptable
substitutes. To be considered an equivalent form,
any substitute must contain all the instructions and
information asked for on this form.
According to CCR Title 8 Section 14300.33
Cal/OSHA’s recordkeeping rule, you must keep
this form on file for 5 years following the year to
which it pertains.
If you need additional copies of this form, you
may photocopy and use as many as you need.
Completed by
Title
Phone Date
Information about the employee
1)
Full name
2)
Street
City State ZIP
3)
Date of birth
4)
Date hired
5)
Male
Female
Information about the physician or other health care
professional
6)
Name of physician or other health care professional
7)
If treatment was given away from the worksite, where was it given?
Facility
Street
City State ZIP
8)
Was employee treated in an emergency room?
Ye s
No
9)
Was employee hospitalized overnight as an in-patient?
Ye s
No
_____________________________________________________________
________________________________________________________________
______________________________________ _________ ___________
______ / _____ / ______
______ / _____ / ______
__________________________
________________________________________________________________________
_________________________________________________________________
_______________________________________________________________
______________________________________ _________ ___________
•
•
•
•
•
•
Information about the case
10)
Case number from the
Log (Transfer the case number from the Log after you record the case.)
11)
Date of injury or illness
12)
Time employee began work
AM / PM
13)
Time of event
AM / PM
Check if time cannot be determined
_____________________
______ / _____ / ______
____________________
____________________
______ / _____ / ______
•
_______________________________________________________
_________________________________________________________________
(________)_________--_____________ _____/ ______ / _____
14)
What was the employee doing just before the incident occurred?
Describe the activity, as well as the
tools, equipment, or material the employee was using. Be specific.
Examples:
“climbing a ladder while
carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.”
15)
What happened?
Tell us how the injury occurred.
Examples:
“When ladder slipped on wet floor, worker
fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker
developed soreness in wrist over time.”
16)
What was the injury or illness?
Tell us the part of the body that was affected and how it was affected; be
more specific than “hurt,” “pain,” or sore.”
Examples:
“strained back”; “chemical burn, hand”; “carpal
tunnel syndrome.”
17)
What object or substance directly harmed the employee?
Examples: “concrete floor”; “chlorine”;
“radial arm saw.” If this question does not apply to the incident, leave it blank.
18)
If the employee died, when did death occur?
Date of death
