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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 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.All establishments covered by Part 1904 must complete this Summary page, even if no 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.Total number of deaths.Total number of cases with days away from work6Total number of cases with job transfer or restrictionNumber of Days3Total number of days of job transfer or restriction#Total number of days away from work&Total number of other recordable casesInjury and Illness TypesNumber of CasesTotal number of& (1) InjuryEstablishment informationYour establishment nameStreetEmployment informationCStandard Industrial Classification (SIC), if known (e.g., SIC 3715)"Annual average number of employees-Total hours worked by all employees last year Sign here8Knowingly 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.Company executiveTitlePhoneDateZip )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 1904.35, in OSHA's Recordkeeping rule, for further details on the access provisions for these forms.(2) Skin Disorder(3) Respiratory Condition(4) PoisoningqPublic 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.qPublic reporting burden for this collection of information is estimated to average 50 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.&Injuries and Illnesses Incident Report Completed by1)2) Full Name Date of birth Date hiredMaleFemaleAInformation about the physician or other health care professional6)3)4)5)3Name of physician or other health care professional7)BIf treatment was given away from the worksite, where was it given?Facility8)YesNo9)10)Case number from the Log11)12)13)Date of injury or illnessTime employee began work Time of eventOSHA's Form 301Information about the employeeInformation about the caseAttention: 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. 14)15)17)18)16):If the employee died, when did death occur? Date of death+-AM/PM *Was employee treated in an emergency room?5Was employee hospitalized overnight as an in-patient? 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 pertainsa If you need additional copies of this form, you may photocopy and use as many as you need.B(Transfer the case number from the Log after you record the case.)"Check if time cannot be determinedt 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.What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than "hurt", "pain", or "sore." Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."This Injury and Illness Incident Report is one of the 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. &   .Summary of Work-Related Injuries and IllnessesUsing 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."@Industry description (e.g., Manufacture of motor truck trailers)"Date of injury or onset of illnessePost this Summary page from February 1 to April 30 of the year following the year covered by the form-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.">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.6Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sou<rces, 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. (mo./day)%On job transfer or restriction (days)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. OSHA's Form 300 (Rev. 01/2004) Hearing LossQCHECK ONLY ONE box for each case based on the most serious outcome for that case:(6)Away From Work (days)(6) All Other Illnesses(5) Hearing LossOSHA's Form 300A (Rev. 01/2004)ORINorth American Industrial Classification (NAICS), if known (e.g., 336212)What happened? Tell us how the injury occurred. 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BohannonUniversity of AlaskaMicrosoft Excel@}@mi@Tl՜.+,D՜.+,D PX|  OSHA - Jackson Area Office' OSHA Form 300OSHA Form 300AOSHA Form 301'OSHA Form 300A'!Print_Area  Worksheets Named Ranges<@0_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_ReviewingToolsShownOnceY excel formsSchmidt.Dave@dol.govSchmidt, Dave - OSHA  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !#$%&'()Root Entry FWorkbook%3SummaryInformation(DocumentSummaryInformation8"