Fill - Free fillable Work-Related Injuries and Illnesses (Department of Labor) PDF form

OSHA

Forms for Recording

Work-Related Injuries and Illnesses

Dear Employer:

This booklet includes the forms needed for maintaining occupational injury and

illness records. Many but not all employers must complete the OSHA injury and

illness recordkeeping forms on an ongoing basis. Employers in State Plan States

should check with their State Plan to see if the exemptions below apply.

Employers with 10 or fewer employees throughout the previous calendar year

do not need to complete these

forms. In addition to the small employer exemption,

there is an exemption for establishments classified in certain industries. A

complete list of exempt industries can be found on the OSHA web page at https://

www.osha.gov/recordkeeping.

Establishments normally exempt from keeping the OSHA forms must complete

the forms if they are informed in writing to do so by the Bureau of Labor Statistics

or OSHA.

All employers, including those partially exempted by reason of company size

or industry classification, must report to OSHA any workplace incident that results

in a fatality, in-patient hospitalization, amputation, or loss of an eye. You can

report to OSHA by calling OSHA's free and confidential number at 1-800-321-

OSHA (6742); calling your closest Area Office during normal business hours; or

by using the online reporting form at https://www.osha.gov/pls/ser/serform.html.

Many employers are required to electronically submit information from their

Form 300A Summary to OSHA. To see if your establishment is required to

submit the information, visit https://www.osha.gov/injuryreporting/index.html.

The Occupational Safety and Health Administration shares with you the goal

of preventing injuries and illnesses in our nation's workplaces. Accurate injury

and illness records will help us achieve that goal.

Occupational Safety and Health Administration

U.S. Depar

tment of Labor

What’s Inside...

In this package, you’ll find everything you need to complete

OSHA’s Log and the Summary of Work-Related Injuries and Illnesses

for the next several years. On the following pages, you’ll find:

▼

An Overview: Recording Work-Related Injuries and Illnesses —

General instructions for filling out the forms in this package and

definitions of terms you should use when you classify your cases as

injuries or illnesses.

▼

How to Fill Out the Log — An example to guide you in filling out the

Log properly.

▼

Log of Work-Related Injuries and

Illnesses —

A copy of the Log (but you

may make as many copies of the Log as

you need.) Notice that the Log is

separate from the Summary.

▼

Summary of Work-Related Injuries

and Illnesses —

Removable Summary

pages for easy posting at the end of the

year. Note that you post the Summary

only, not the Log.

▼

Worksheet to Help You Fill Out the Summary — A worksheet for

figuring the average number of employees who worked for your

establishment and the total number of hours worked.

▼

OSHA’s 301: Injury and Illness

Incident Report —

A copy of the OSHA

301 to provide details about the incident.

You may make as many copies as you

need or use an equivalent form.

Take a few minutes to review this package. If you have any questions,

visit us online at www.osha.gov or call your local OSHA office. We’ll be

happy to help you.

U.S. Department of Labor

Occupational Safety and Health Administration

An Overview:

Recording Work-Related Injuries and Illnesses

The Occupational Safety and Health (OSH) Act of 1970 requires certain employers to prepare and maintain records of work-related injuries and illnesses. Use these

definitions when you classify cases on the Log. OSHA’s recordkeeping regulation (see 29 CFR Part 1904) provides more information about the definitions below.

What do you need to do?

1. Within 7 calendar days after you receive

information about a case, decide if the

case is recordable under the OSHA

recordkeeping requirements.

2. Determine whether the incident is a new

The Log of Work-Related Injuries and Illnesses

(Form 300) is used to classify work-related

injuries and illnesses and to note the extent and

severity of each case. When an incident occurs,

use the Log to record specific details about what

happened and how it happened. The Summary —

a separate form (Form 300A) — shows the totals

for the year in each category. At the end of the

year, post the Summary in a visible location so

that your employees are aware of the injuries and

illnesses occurring in their workplace.

Employers must keep a Log for each

establishment or site. If you have more than one

establishment, you must keep a separate Log and

Summary for each physical location that is

expected to be in operation for one year or

longer.

Note that your employees have the right to

review your injury and illness records. For more

information, see 29 Code of Federal Regulations

Part 1904.35, Employee Involvement.

Cases listed on the Log of Work-Related

Injuries and Illnesses are not necessarily eligible

for workers’ compensation or other insurance

benefits. Listing a case on the Log does not mean

that the employer or worker was at fault or that

an OSHA standard was violated.

When is an injury or illness considered

work-related?

An injury or illness is considered work-

related if an event or exposure in the work

environment caused or contributed to the

condition or significantly aggravated a

preexisting condition. Work-relatedness is

presumed for injuries and illnesses resulting

from events or exposures occurring in the

workplace, unless an exception specifically

applies.

See 29 CFR Part 1904.5(b)(2) for the

exceptions. The work environment includes the

establishment and other locations where one or

more employees are working or are present as a

condition of their employment. See 29 CFR Part

1904.5(b)(1).

Which work-related injuries and

illnesses should you record?

Record those work-related injuries and illnesses

that result in:

▼

death,

▼

loss of consciousness,

▼

days away from work,

▼

restricted work activity or job transfer, or

▼

medical treatment beyond first aid.

You

must also record work-related injuries

and illnesses that are significant (as defined

elow) or meet any of the additional criteria

listed below.

You must record any significant work-

related injury or illness that is diagnosed by a

physician or other licensed health care

professional. You must record any work-related

case involving cancer, chronic irreversible

disease, a fractured or cracked bone, or a

punctured eardrum. See 29 CFR 1904.7.

What are the additional criteria?

You must record the following conditions when

they are work-related:

▼

any needlestick injury or cut from a sharp

object that is contaminated with another

person’s blood or other potentially infectious

material;

▼

any case requiring an employee to be

medically removed under the requirements

of an OSHA health standard;

▼

tuberculosis infection as evidenced by a

positive skin test or diagnosis by a physician

or other licensed health care professional

after exposure to a known case of active

tuberculosis;

▼

an employee's hearing test (audiogram)

reveals 1) that the employee has experienced

a Standard Threshold Shift (STS) in hearing

in one or both ears (averaged at 2000, 3000,

and 4000 Hz) and 2) the employee's total

hearing level is 25 decibels (dB) or more

above audiometric zero (also averaged at

2000, 3000, and 4000 Hz) in the same ear(s)

as the STS.

What is medical treatment?

Med

ical treatment includes managing and caring

for a patient for the purpose of combating

sease

sorder.

ollo

wing

are not

nsidered

medical

reatments

e NOT

ecordable:

▼

visits to a doctor or health care professional

solely for observation or counseling;

case or a recurrence of an existing one.

3. Establi

sh whether the case was work-

related.

4. If the case is recordable, decide which

form you will fill out as the injury and

illness incident report.

You may use OSHA’s 301: Injury

and Illness Incident Report or an

equivalent form. Some state workers

compensation, insurance, or other reports

may be acceptable substitutes, as long as

they provide the same information as the

OSHA 301.

How to work with the Log

1. Identify the employee involved unless it is

a privacy concern case as described

below.

2. Identify when and where the case

occurred. Also describe the case, as

specifically as you can.

3. Classify the seriousness of the case by

recording the most serious outcome

associated with the case, with column G

(Death) being the most serious and

column J (Other recordable cases) being

the least serious.

4. Enter the number of days the injured or ill

worker was away from work or was on

job transfer or restricted work activity.

5. Identify whether the case is an injury or

illness. If the case is an injury, check the

injury category. If the case is an illness,

check the appropriate illness category.

U.S. Department of Labor

Occupational Safety and Health Administration

▼

diagnostic procedures, including administering

prescription medications that are used solely

for diagnostic purposes; and

▼

any procedure that can be labeled first aid. (See

below for more information about first aid.)

What is first aid?

If the incident required only the following types of

treatment, consider it first aid. Do NOT record the

case if it involves only:

▼

using non-prescription medications at non-

prescription strength;

▼

administering tetanus immunizations;

▼

cleaning, flushing, or soaking wounds on the

skin surface;

▼

using wound coverings, such as bandages,

BandAids™, gauze pads, etc., or using

SteriStrips™ or butterfly bandages;

▼

using hot or cold therapy;

▼

using any totally non-rigid means of support,

such as elastic bandages, wraps, non-rigid back

belts, etc.;

▼

using temporary immobilization devices while

transporting an accident victim (splints, slings,

neck collars, or back boards);

▼

drilling a f ingernail or toenail to relieve

pressure, or draining fluids from blisters;

▼

using eye patches;

▼

using simple irrigation or a cotton swab to

remove foreign bodies not embedded in or

adhered to the eye;

▼

using irrigation, tweezers, cotton swab or other

simple means to remove splinters or foreign

material from areas other than the eye;

▼

using finger guards;

▼

using massages;

▼

drinking fluids to relieve heat stress.

How do you decide if the case

involved restricted work?

Restricted work activity occurs when, as the result

of a work-related injury or illness, an employer or

health care professional keeps, or recommends

keeping, an employee from doing the routine

functions of his or her job or from working the

full workday that the employee would have been

scheduled to work before the injury or illness

occurred.

How do you count the number of

days of restricted work activity or

the number of days away from work?

Count the number of calendar days the employee

was on restricted work activity or was away from

work as a result of the recordable injury or illness.

Do not count the day on which the injury or

illness occurred in this number. Begin counting

days from the day after the incident occurs. If a

single injury or illness involved both days away

from work and days of restricted work activity,

enter the total number of days for each. You may

stop counting days of restricted work activity or

days away from work once the total of either or

the combination of both reaches 180 days.

Under what circumstances should

you NOT enter the employee’s name on

the OSHA Form 300?

You must consider the following types of injuries

or illnesses to be privacy concern cases:

▼

an injury or illness to an intimate body part or to

the reproductive system,

▼

an i njury o r illness resulting f rom a sexual

assault,

▼

a mental illness,

▼

a case of HIV i nfection, hepatitis, or

tuberculosis,

▼

a needlestick injury or cut from a sharp object

that is contaminated with blood or other

potentially infectious material (see 29 CFR Part

1904.8 for definition), and

▼

other illnesses, if the employee independently

and voluntarily requests that his or her name not

be entered on the log.

You must not enter the employee’s name on the

SHA 300 Log for these cases. Instead, enter

“privacy case” in the space normally used for the

employee’s name. You must keep a separate,

confidential list of the case numbers and employee

names for the establishment’s privacy concern

cases so that you can update the cases and provide

information to the government if asked to do so.

If you have a reasonable basis to believe that

information describing the privacy concern case

may be personally identifiable even though the

employee’s name has been omitted, you may use

discretion in describing the injury or illness on

both the OSHA 300 and 301 forms. You must

enter enough information to identify the cause of

the incident and the general severity of the

injury or illness, but you do not need to include

details of an intimate or private nature.

What if the outcome changes after you

record the case?

If the outcome or extent of an injury or illness

changes after you have recorded the case,

simply draw a line through the original entry or,

if you wish, delete or white-out the original

entry. Then write the new entry where it

belongs. Remember, you need to record the

most serious outcome for each case.

Classifying injuries

An injury is any wound or damage to the body

resulting from an event in the work

environment.

Examples: Cut, puncture, laceration,

abrasion, fracture, bruise, contusion, chipped

tooth, amputation, insect bite, electrocution, or

a thermal, chemical, electrical, or radiation

burn. Sprain and strain injuries to muscles,

joints, and connective tissues are classified as

injuries when they result from a slip, trip, fall or

other similar accidents.

U.S. Department of Labor

Occupational Safety and Health Administration

U.S. Department of Labor

Occupational Safety and Health Administration

Classifying illnesses

Skin diseases or

disorders

Skin diseases or disorders are illnesses involving

the worker’s skin that are caused by work

exposure to chemicals, plants, or other

substances.

Examples: Contact dermatitis, eczema, or

rash caused by primary irritants and sensitizers

or poisonous plants; oil acne; friction blisters;

chrome ulcers; inflammation of the skin.

Respiratory conditions

Respiratory conditions are illnesses associated

with breathing hazardous biological agents,

chemicals, dust, gases, vapors, or fumes at work.

Examples: Silicosis, asbestosis, pneumonitis,

pharyngitis, rhinitis or acute congestion;

farmer’s lung, beryllium disease, tuberculosis,

occupational asthma, reactive airways

dysfunction syndrome (RADS), chronic

obstructive pulmonary disease (COPD),

hypersensitivity pneumonitis, toxic inhalation

injury, such as metal fume fever, chronic

obstructive bronchitis, and other

pneumoconioses.

Poisoning

Poisoning includes disorders evidenced by

abnormal concentrations of toxic substances in

blood, other tissues, other bodily fluids, or the

breath that are caused by the ingestion or

absorption of toxic substances into the body.

Examples: Poisoning by lead, mercury,

cadmium, arsenic, or other metals; poisoning by

carbon monoxide, hydrogen sulfide, or other

gases; poisoning by benzene, benzol, carbon

tetrachloride, or other organic solvents;

poisoning by insecticide sprays, such as

parathion or lead arsenate; poisoning by other

chemicals, such as formaldehyde.

Hearing Loss

Noise-induced hearing loss is defined for

recordkeeping purposes as a change in hearing

threshold relative to the baseline audiogram of an

average of 10 dB or more in either ear at 2000,

3000, and 4000 hertz, and the employee’s total

hearing level is 25 decibels (dB) or more above

audiometric zero (also averaged at 2000, 3000,

and 4000 hertz) in the same ear(s).

All other illnesses

All other occupational illnesses.

Examples: Heatstroke, sunstroke, heat

exhaustion, heat stress and other effects of

environmental heat; freezing, frostbite, and other

effects of exposure to low temperatures;

decompression sickness; effects of ionizing

radiation (isotopes, x-rays, radium); effects of

nonionizing radiation (welding flash, ultra-violet

rays, lasers); anthrax; bloodborne pathogenic

diseases, such as AIDS, HIV, hepatitis B or

hepatitis C; brucellosis; malignant or benign

tumors; histoplasmosis; coccidioidomycosis.

When must you post the Summary?

You must post the Summary only — not the

Log — by February 1 of the year following the

year covered by the form and keep it posted

until April 30 of that year.

How long must you keep the Log and

Summary on

file?

You must keep the Log and Summary for 5 years

following the year to which they pertain.

Do you have to send these forms to

OSHA at the end of the

year?

Many employers are required to electronically

submit information from their Form 300A

Summary to OSHA. To see if your establishment

is required to submit the information, visit https://

www.osha.gov/injuryreporting/index.html.

How can we help you?

If you have a question about how to

fill out the Log

▼

visit us online at www.osha.gov or

▼

call your local OSHA office.

Calculating Injury and Illness Incidence Rates

What is an incidence rate?

An incidence rate is the number of recordable

injuries and illnesses occurring among a given

number of full-time workers (usually 100 full-

time workers) over a given period of time

(usually one year). To evaluate your firm’s injury

and illness experience over time or to compare

your firm’s experience with that of your industry

as a whole, you need to compute your incidence

rate. Because a specific number of workers and a

specific period of time are involved, these rates

can help you identify problems in your workplace

and/or progress you may have made in preventing

work-related injuries and illnesses.

worked during the year. Refer to OSHA Form

300A and optional worksheet to calculate this

number.

You can compute the incidence rate for all

recordable cases of injuries and illnesses using the

following formula:

Total number of injuries and illnesses

X 200,000 ÷

Number of hours worked by all employees = Total

recordable case rate

(The 200,000 figure in the formula represents the

number of hours 100 employees working 40 hours

per week, 50 weeks per year would work, and

provides the standard base for calculating

various classifications (e.g., by industry, by

employer size, etc.). You can obtain these

published data at www.bls.gov/iif

or by calling

a BLS Regional Office.

Worksheet

Total number of

injuries and illnesses

Number of

hours worked

by all employees

Total recordable

case rate

How do you calculate an incidence

rate?

You can compute an occupational injury and

illness incidence rate for all recordable cases or

for cases that involved days away from work for

your firm quickly and easily. The formula

requires that you follow instructions in paragraph

(a) below for the total recordable cases or those in

paragraph (b) for cases that involved days away

from work, and for both rates the instructions in

paragraph (c).

(a) To find out the total number of recordable

injuries and illnesses that occurred during the

year, count the number of line entries on your

OSHA Form 300, or refer to the OSHA Form

300A and sum the entries for columns (H), (I),

and (J).

(b) To find out the number of injuries and

illnesses that involved days away from work,

count the number of line entries on your OSHA

Form 300 that received a check mark in column

(H), or refer to the entry for column (H) on the

OSHA Form 300A.

inci

dence rates.)

You can compute the incidence rate for

recordable cases involving days away from work,

days of restricted work activity or job transfer

(DART) using the following formula:

(Number of entries in column H + Number of

entries in column I)

X 200,000 ÷ Number of hours

worked by all employees = DART incidence rate

You can use the same formula to calculate

incidence rates for other variables such as cases

involving restricted work activity (column (I) on

Form 300A), cases involving skin disorders

(column (M-2) on Form 300A), etc. Just substitute

the appropriate total for these cases, from Form

300A, into the formula in place of the total number

of injuries and illnesses.

What can I compare my incidence rate

to?

The Bureau of Labor Statistics (BLS) conducts a

survey of occupational injuries and illnesses each

year and publishes incidence rate data by

Number of entries in

Column H + Column I

X 200,000

Number of

hours worked

by all employees

X 200,000

DART incidence

rate

Optional

Reset

Note:

You can type input into this form and save it.

Because the forms in this recordkeeping package are “fillable/writable”

PDF documents, you can type into the input form fields and

then save your inputs using the free Adobe PDF Reader. In addition,

the forms are programmed to auto-calculate as appropriate.

U.S. Department of Labor

Occupational Safety and Health Administration

Reset

How to Fill Out the Log

The Log of Work-Related Injuries and

Ill

nesses is used to classify work-related

injuries and illnesses and to note the

extent and severity of each case. When an

incident occurs, use the Log to record

specific details about what happened and

how it happened.

If your company has more than one

establishment or site, you must keep

separate records for each physical location

that is expected to remain in operation for

one year or longer.

If you need additional copies of the

Log, you may photocopy the printout or

insert additional form pages in the PDF,

and then use as many as you need.

The Summary — a separate form —

shows the work-related injury and illness

totals for the year in each category. At the

end of the year, count the number of

incidents in each category and transfer the

totals from the Log to the Summary. Then

post the Summary in a visible location so

that your employees are aware of injuries

and illnesses occurring in their workplace.

You don’t post the Log. You post

only the Summary at the end of the year.

Be as specific as possible. You can

use two lines if you need more

room.

Revise the log if the injury or illness

progresses and the outcome is more serious

than you originally recorded for the case.

Cross out, erase, or white-out the original

entry if hard copy. (If using the PDF's fillable form

feature, simply change your selections. You can

also clear the entire case entry from the log using

the Reset button.)

Choose ONLY ONE of these

categories. Classify the case by

recording the most

serious outcome of the case,

with column G (Death) being

the most serious and column

J (Other recordable cases)

being the least serious.

Note whether the

case involves an

injury or an illness.

Note: Because the forms in this recordkeeping package are “fillable/

writable” PDF documents, you can type into the input form fields and

then save your inputs using the free Adobe PDF Reader. In addition,

the forms are programmed to auto-calculate as appropriate.

U.S. Department of Labor

Occupational Safety and Health Administration

Step 3. Classify the case

SELECT ONLY ONE circle based on the

most serious outcome:

(J) (I)(H)

Remained at Work

Days away Job transfer Other record-

from work or restriction able cases

Death

(G)

Step 4.

OSHA’s Form 300 (Rev. 04/2004)

Log of Work-Related

Injuries and Illnesses

Please 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.

• Significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional.

• Work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8

through 1904.12.

Reminders:

• Complete an Injury and Illness Incident Report (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 OSHA office for help.

• Feel free to use two lines for a single case if you need to.

• Complete the 5 steps for each case.

Establishment name

City

Year 20

U.S. Department of Labor

Occupational Safety and Health Administration

Form approved OMB no. 1218-0176

State

(A) (B) (C) (D) (E) (F)

Enter the number of

Case

no.

Employee’s name

Job title

(e.g., Welder)

Date of injury

or onset of

illness

Where the event occurred

(e.g., Loading dock north end)

Describe injury or illness, parts of body

affected, and object/substance that

directly injured or made person ill (e.g.,

days the injured or ill

worker was:

(e.g., 2/10)

Second degree burns on right forearm from

acetylene torch)

Away

from

work

On job

transfer or

restriction

month / day

(K) (L)

days

days days

Page totals

Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review the

instructions, search and gather the data needed, and complete and review the collection of information. Persons are not required to

respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these

estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room

N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.

Be sure to transfer these totals to the Summary page (Form 300A) before you post it.

(1) (2) (3) (4) (5)

(6)

Illness

(M)

(1) (2) (3) (4) (5) (6)

Step 2. Describe the case

Reset

Add a Form Page

Select one column:

Step 5.

Step 1. Identify the person

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.

Note:

You can type input into this form and save it.

Because the forms in this recordkeeping package are “fillable/writable”

PDF documents, you can type into the input form fields and

then save your inputs using the free Adobe PDF Reader. In addition,

the forms are programmed to auto-calculate as appropriate.

▼

Injury

Skin disorder

Respiratory

condition

Respiratory

condition

Poisoning

Hearing loss

All other

illnesses

All other

illnesses

Reset

Add a Form Page

Total hours worked by all employees last year

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.

Title Company executive

Phone

Date

Annual average number of employees

Employment information (If you don't have these figures, see the

Worksheet on the next page to estimate.)

North American Industrial Classification (NAICS), if known (e.g., 336212)

Industry description (e.g., Manufacture of motor truck trailers)

Zip

Establishment information

Your establishment name

Street

City

State

OSHA’s Form 300A

(Rev. 04/2004)

Summary of Work-Related Injuries and Illnesses

Year 20

U.S. Department of Labor

Occupational Safety and Health Administration

All establishments covered by Part 1904 must complete this Summary page, 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 OSHA Form 300 in its entirety. They also have limited access

to the OSHA Form 301 or its equivalent. See 29 CFR Part 1904.35, in OSHA’s recordkeeping rule, for further details on the access provisions for

these forms.

Form approved OMB no. 1218-0176

Total number of

deaths

Total number of

cases with days

away from work

Total number of cases

with job transfer or

restriction

Total number of

other recordable

cases

(G) (H) (I) (J)

Total number of days

away from work

Total number of days of

job transfer or restriction

(K) (L)

Total number of . . .

(M)

(1)

Injuries

(2)

Skin disorders

(3)

Respiratory conditions

(4)

Poisonings

(5)

Hearing loss

(6)

All other illnesses

Post this Summary page from February 1 to April 30 of the year following the year covered by the form.

Public reporting burden for this collection of information is estimated to average 58 minutes per response, including time to review the instructions, search and gather the data needed, and

complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any

comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW,

Washington, DC 20210. Do not send the completed forms to this office.

Number of Days

Number of Cases

Injury and Illness Types

Note:

You can type input into this form and save it.

Because the forms in this recordkeeping package are “fillable/writable”

PDF documents, you can type into the input form fields and

then save your inputs using the free Adobe PDF Reader.

Reset

U.S. Department of Labor

Occupational Safety and Health Administration

Optional

Worksheet to Help You Fill Out the Summary

Note: You can type input into this form and save it.

Because the forms in this recordkeeping package are “fillable/

writable” PDF documents, you can type into the input form fields and

then save your inputs using the free Adobe PDF Reader. In addition,

the forms are programmed to auto-calculate as appropriate.

At the end of the year, OSHA requires you to enter the average number of employees and the total hours your employees worked on the Summary. If you don’t have these figures, you can use the information on this

page to estimate the numbers you will need to enter on the Summary page.

If you pay about the same number of employees every pay period throughout the year (e.g., about 100),

then you can use that number as your annual average employment. If the number of employees fluctuates

from pay period to pay period (e.g., your business is seasonal or your establishment grew or shrunk during

the year), then you should use the formula below to calculate employment average.

How to figure the average number of employees who worked for your establishment during the year:

Add up and then enter the number of employees your

establishment paid IN EACH PAY PERIOD during

the year. Be sure to include all employees: full-time,

part-time, temporary, seasonal, salaried, and hourly.

The total number of

employees paid in all pay

periods throughout the year =

Count and then enter the number of pay periods your

establishment had during the year. Be sure to include

any pay periods when you had no employees. For

example, enter 26 if you have biweekly pay periods

or 52 if you have weekly pay periods.

The number of pay

periods during the year =

pay periods. (See auto-calc.)

Round the answer to the next highest whole

The number rounded =

number (See auto-calc.). Write the rounded

number in the blank on the Summary page

marked Annual average number of employees.

For example, Acme Construction figured its average employment this way:

In this pay period . . . Acme paid this many employees . . .

1 10

Number of employees paid = 830

2 0

3 15

Number of pay periods = 26

4 30

830 = 31.92

5 40

▼ ▼

24 20

31.92 rounds to 32

25 15

26 +10

32 is the annual average number of employees

830

How to figure the total hours all employees worked:

Include hours worked by salaried, hourly, part-time, and seasonal workers,

as well as hours worked by other workers subject to day-to-day supervision

by your establishment (e.g., temporary help service workers).

Do not include vacation, sick leave, holidays, or any other non-work time,

even if employees were paid for it. If your establishment keeps records of

only the hours paid, or if you have employees who are not paid by the hour,

please estimate the hours that the employees actually worked.

If this number isn’t available, you can use this optional worksheet to

estimate it.

Optional Worksheet

Find the number of full-time employees in your

establishment for the year.

x Multiply by the number of work hours for a full-time

employee in a year.

This is the number of full-time hours worked.

+ Add the number of any overtime hours as well as the

hours worked by other employees (part-time,

temporary, seasonal).

Round the answer to the next highest whole number.

Write

the

rounded

number

the

blank

the

Summary page marked Total hours worked by all

employees last year.

Reset

Divide the number of employees by the number of

Note: Review your annual average number

of employees to ensure it makes sense. Is it

about the same as the number of employees

working at your establishment on any given

day? Is it bigger than your smallest number

of employees in a pay period? Is it smaller

than your biggest number of employees in a

pay period? If the answer to any of these

questions is “no,” then the calculation may

be incorrect.

Note: You CANNOT divide the total

number of W2s by the number of pay

periods to calculate average employment.

You must add up the number of employees

paid IN EACH PAY PERIOD and then

divide by the number of pay periods.

0.00

Reset

OSHA’s Form 301

(Rev. 04/2004)

Injury and Illness

Incident Report

U.S. Department of Labor

Occupational Safety and Health Administration

This Injury and Illness Incident Report is one of the

Information about the employee

Information about the case

Form approved OMB no. 1218-0176

first forms you must fill out when a recordable

work-related injury or illness has occurred. Together

with the Log of Work-Related Injuries and Illnesses

and the accompanying Summary, these forms help

the employer and 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 information asked for

on this form.

According to Public Law 91-596 and 29 CFR

1904, 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 the printout or insert additional form

pages in the PDF, and then use as many as you need.

Full name

2) Street

City State ZIP

3) Date of birth

Month Day Year

Date hired

Month Day Year

Male Female

Information about the physician or other health care

professional

Name of physician or other health care professional

If treatment was given away from the worksite, where was it given?

Facility

Street

City State

̀ZIP

Was employee treated in an emergency room?

Yes

(Transfer the case number from the Log after you record the case.)

Month Day Year

AM PM

10) Case number from the Log

11) Date of injury or illness

12) Time employee began work (HH:MM)

13) Time of event (HH:MM)

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.

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.

Was employee hospitalized overnight as an in-patient?

Yes

18)

If the employee died, when did death occur? Date of death

Month Day Year

Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Persons are not required to respond to the collection of information unless it displays a

current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.

Re fields 14 to 17: Please do not include any personally identifiable information (PII) pertaining to

worker(s) involved in the incident (e.g., no names, phone numbers, or Social Security numbers).

Month Day Year

Date

Completed by

Title

Phone

Add a Form Page

Reset

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.

Note: You can type input into this form and save it.

Because the forms in this recordkeeping package are “fillable/writable”

PDF documents, you can type into the input form fields and

then save your inputs using the free Adobe PDF Reader. In addition,

the forms are programmed to auto-calculate as appropriate.

Reset

Add a Form Page

If You Need Help...

If you need help deciding whether a case is recordable, or if you have questions about the

information in this package, feel free to contact us. We’ll gladly answer any questions you have.

Federal Jurisdiction

State Plan States

▼

Visit us online at

www.osha.gov

▼

Call your OSHA Regional office

and ask for the recordkeeping

coordinator

▼

Call your State Plan office

Region 1 - 617 / 565-9860

Connecticut; Massachusetts; M

aine; New

Hampshire; Rhode Island

Region 2 - 212 / 337-2378

New York; New Jersey

Region 3 - 215 / 861-4900

DC; Delaware; Pennsylvania; West Virginia

Region 4 - 678 / 237-0400

Alabama; Florida; Georgia; Mississippi

Region 5 - 312 / 353-2220

Illinois; Ohio; Wisconsin

Region 6 - 972 / 850-4145

Arkansas; Louisiana; Oklahoma; Texas

Region 7 - 816 / 283-8745

Kansas; Missouri; Nebraska

Region 8 - 720 / 264-6550

Colorado; Montana; North Dakota; South

Dakota

Region 9 - 415 / 625-2547

Region 10 - 206 / 553-5930

Idaho

Alaska

Arizona

California

*Connecticut

Hawaii

*Illinois

Indiana

Iowa

Kentucky

*Maine

Maryland

Michigan

Minnesota

Nevada

*New Jersey

New Mexico

*New York

North Carolina

Oregon

Puerto Rico

South Carolina

Tennessee

Utah

Vermont

Virginia

*Virgin Islands

Washington

Wyoming

*Public Sector only

U.S. Department of Labor

Occupational Safety and Health Administration

www.osha.gov/stateplans

Have questions?

If you need help in filling out the Log or Summary, or if you

have questions about whether a case is recordable, contact

us. We’ll be happy to help you. You can:

▼ Visit us online at:

www.osha.gov

▼ Call your regional or state plan office. You’ll find

the phone number listed on the previous page.

U.S. Department of Labor

Occupational Safety and Health Administration

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