New York State
Department of Labor
Log of Work Related Injuries and Illnesses Form
SH-900
1. This form is required by the Commissioner of Labor’s Rules and Regulations
Part 801 (12 NYCRR Part 801) and must be kept in the establishment for five
years. Failure to maintain this form can result in the issuance of a Notice of
Violation and Order to Comply.
2. 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 injures and
illnesses that meet any of the specific recording criteria found in 12 NYCRR 801.7 - 801.12 and
instructions.
3. Use more than one line for a single case if necessary.
4. 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. Refer to the instructions (SH-901) for types of illness and injuries
defined as privacy concern cases.
Calendar Year 20 ____
Page ____of ____
A.Case No.
B. Employee Name
D. Date of
Injury or Onset
of Ilness
(Mo./day)
Using these categores, check
ONLY the most serious result
for each case.
E. Where the Event
Occurred (e.g., Loading
dock, north end)C. Job Title
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)
G. Death
H. Days
Away From
Work
Remained at Work
I. Job Transfer
or Restriction
J. Other
Recordable
Cases
Enter No. of
Days Injured or
Ill Worker Was:
K. Away from
Work
M. Check the Injury Column
or Check One Type of Illness
Political Subdivision (Employer)
Establishment Name
Street Address
City
State Zip Code
TOTALS
SH 900 (1-08)
Additional forms and information: If you require additional forms or information concerning the completion of this form, contact: Department of Labor,
Division of Research and Statistics, 75 Varick St., 7th Floor, New York, NY 10013. Telephone (212) 775-3344.
1. Injury
4. Poisoning
5. Hearing Loss
2. Skin Disorder
3. Respiratory
Condition
6. All Other
Illnesses
L. On Job
Transfer or
restriction
