Attention: This form contains information relating to
OSHA's Form 301 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
Injuries and Illnesses Incident Report occupational safety and health purposes.
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
Information about the employee Information about the case
1) Full Name 10) Case number from the Log (Transfer the case number from the Log after you record the case.)
This Injury and Illness Incident Repor t is one of the 2) Street 11) Date of injury or illness
first forms you must fill out when a recordable work-
related injury or illness has occurred. Together City State Zip 12) Time employee began work AM/PM
with the Log of Work-Related injuries and Illnesses
and the accompanying Summary , these forms help 3) Date of birth 13) Time of event AM/PM Check if time cannot be determined
the employer and OSHA develop a picture of the *Please do not include any personally identifiable information (PII) pertaining to worker(s) involved in the incident (e.g., no names,
extent and severity of work-related incidents. phone numbers, or SSNs) in the following fields.
Within 7 calendar days after you receive 4) Date hired *14) What was the employee doing just before the incident occurred? Describe the activity, as well
information that a recordable work-related injury or as the tools, equipment or material the employee was using. Be specific. Examples: "climbing a
illness has occurred, you must fill out this form or 5) Male ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-
an equivalent. Some state workers' compensation, Female entry."
insurance, or other reports may be acceptable
substitutes. To be considered an equivalent form, Information about the physician or other health care
any substitute must contain all the information professional
asked for on this form. *15) What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor,
According to Public Law 91-596 and 29 CFR 6) Name of physician or other health care professional worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement";
1904, OSHA's recordkeeping rule, you must keep "Worker developed soreness in wrist over time."
this form on file for 5 years following the year to
which it pertains
If you need additional copies of this form, you 7) If treatment was given away from the worksite, where was it given?
may photocopy and use as many as you need.
Facility *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."
Street
City State Zip
8) Was employee treated in an emergency room?
Completed by Yes *17) What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine";
No "radial arm saw." If this question does not apply to the incident, leave it blank.
Title
9) Was employee hospitalized overnight as an in-patient?
Phone Date Yes
No 18) If the employee died, when did death occur? Date of death
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
Statistics, Room N-3644, 200 Constitution Ave, NW, Washington, DC 20210. Do not send the completed forms to this office.
