Attention: This form contains information relating
to employee health and must be used in a manner
OSHA's Form 300 (Rev. 01/2004) that protects the confidentiality of employees to the Year 2010
extent possible while the information is being used
Log of Work-Related Injuries and Illnesses for occupational safety and health purposes. U.S. Department of Labor
Occupational Safety and Health Administration
You must record information 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 Form approved OMB no. 1218-0176
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 29 CFR 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must
Establishment name ABC Company
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.
City Safe City State NJ
Identify the person Describe the case Classify the case
Enter the number of
(A) (B) (C) (D) (E) (F) CHECK ONLY ONE box for each case based on days the injured or ill Check the "injury" column or choose one type
Case Employee's Name Job Title (e.g., Date of Where the event occurred (e.g. Describe injury or illness, parts of body affected, the most serious outcome for that case: worker was: of illness:
No. Welder) injury or Loading dock north end) and object/substance that directly injured or
All other illnesses
onset of made person ill (e.g. Second degree burns on (M)
illness right forearm from acetylene torch) On job
Skin Disorder
Hearing Loss
Days away Away
Death Remained at work transfer or
Respiratory
(mo./day) from work From
Poisoning
Condition
restriction
Job transfer Other record- Work (days)
Injury
or restriction able cases (days)
(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6)
Right shoulder and neck sprain from lifting totes -
1 Tammy Newcomer Price Selector 1/20/10 General Mechandise A-1 Sprain/Strain. Right Shoulder - Totes X 18 0 X
General Merchandise Quick
Merchandise-Quick Laceration fo right thumb from knife Cut/Punture
knife-Cut/Punture.
2 Pat James Chute Loader 2/3/10 pick fingers Right Thumb - Knife X 0 0 X
Caught left foot between jack and push back rack-
3 Jose Ortega Maintenance 3/17/10 General Merchandise-Aisle 528 Fracture, Left Foot-Pallet Jack X 165 0 X
Daily data entry into computer workstation-Carpal
Administrative Tunnel Syndrome, Right Wrist-Computer
4 Georgina Gonzella Clerk 3/24/10 General Office workstation X 45 0 X
Difficulty breathing after box of powdered
5 William Handwerk Loader 4/7/2010 Grocery Aisle #42 detergent spilled-asthma attack, lungs, detergent X 1 0 X
6 Privacy Case Privacy Case 5/28/10 Privacy Case Needlestick from syringe-Right hand X 0 0 X
Debris in left eye while working-Foreign body in
7 Ellen Bass Selector 7/20/10 Perishable eye-left eye X 6 0
Page totals 0 5 0 2 235 0 4 0 1 0 0 1
All other illnesses
Injury
Skin Disorder
Respiratory
Condition
Poisoning
Hearing Loss
Be sure to transfer these totals to the Summary page (Form 300A) before you post it.
Public reporting burden for this collection of information is estimated to average 14 minutes per response, including
time to review the instruction, 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 aspects of this data collection, 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. Page 1 of 1 (1) (2) (3) (4) (5) (6)
