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Cal/OSHA Form 300 (Rev. 7/2007) Appendix A
Log of Work-Related Injuries and Illnesses
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)
Year 20
Department of Industrial Relations
Division of Occupational Safety and Health
You must record information about every work-related death and 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 CCR Title 8 Section 14300.8 through 14300.12. Feel free to
use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (Cal/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 Cal/OSHA office for help.
Establishment name
City State
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________________________________
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Identify the person Describe the case Classify the case
(A)
Case
no.
(B)
Employee’s name
(C)
Job title
(e.g., Welder)
(D)
Date of injury
or onset
of illness
(E)
Where the event occurred
e.g., Loading dock north( end)
(F)
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)
Using these four categories, check ONLY
the most serious result for each case:
Death
Days away
from work
Enter the number of
days the injured or
ill worker was:
Check the “Injury” column or
choose one type of illness:
(G) (H)
Job transfer
or restriction
(I)
Other record-
able cases
(J)
(K) (L)
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(M)
(1)
Injury
(2)
Skin disorder
(3)
Respiratory
condition
(4)
Poisoning
(5)
Hearing loss
s
(6)
All other
Illnesses
month/day
days days
month/day
days days
month/day
days days
month/day
days days
month/day
days days
month/day
days days
month/day
days days
month/day
days days
month/day
days days
month/day
days days
month/day
days days
month/day
days days
month/day
days days
Page totals
Be sure to transfer these totals to the Summary page (Form 300A) before you post it.
(1)
Injury
(2)
Skin disorder
(3)
Respiratory
condition
(4)
Poisoning
(5)
Hearing loss
(6)
All other
Illnesses
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Page of
On job
transfer or
restriction
