OSHA Form 300 - Free Download
4.3, 2928 votes
Please vote for this template if it helps you.
OSHA Form 300
OSHA Form 300
OSHA Form 300
Log of Work-Related Injuries and Illnesses
Year 20
     
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
Department of Consumer & Business
Services
Oregon Occupational Safety &
Health Division (OR-OSHA)
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, job transfer, days away from work, or medical treatment beyond first aid. You must also record significant work-related
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 OAR 437-001-0700. Use more lines for each case if needed. You must complete an Injury and
Illness Incident Report (DCBS form 801) 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 OR-OSHA office for help.
Establishment name:      
City:       State:      
Identify the person Describe the case Classify the case
(A)
Case no.
(B)
Employee’s name
(C)
Job title
(e.g., “welder”)
(D)
Date of
injury or
illness
(E)
Where the event
occurred (e.g.,
“loading dock -
north end”
(F)
Describe Injury/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”)
Using these 4 categories,
enter “1” in only the most
serious result for each
case:*
Enter the number of
days the injured /
worker was:
Enter “1” in the “injury” column
or choose one type of illness:*
(M)
Death Days
away
from
work
Remained at
work
Injury
Skin disorder
Respiratory condition
Poisoning
Hearing Loss
All other illnesses
Job
transf
er or
restric
tion
Other
record-
able
cases
Away
from
work
On job
transfer or
restriction
(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6)
                                    0 0 0 0     days     days 0 0 0 0 0 0
                                    0 0 0 0     days     days 0 0 0 0 0 0
                                    0 0 0 0     days     days 0 0 0 0 0 0
                                    0 0 0 0     days     days 0 0 0 0 0 0
                                    0 0 0 0     days     days 0 0 0 0 0 0
                                    0 0 0 0     days     days 0 0 0 0 0 0
                                    0 0 0 0     days     days 0 0 0 0 0 0
                                    0 0 0 0     days     days 0 0 0 0 0 0
                                    0 0 0 0     days     days 0 0 0 0 0 0
                                    0 0 0 0     days     days 0 0 0 0 0 0
                                    0 0 0 0     days     days 0 0 0 0 0 0
                                    0 0 0 0     days     days 0 0 0 0 0 0
                                    0 0 0 0     days     days 0 0 0 0 0 0
Page Totals 0 0 0 0 0 days 0 days 0 0 0 0
0 0
Be sure to transfer these totals to the Summary (OSHA Form 300A) before you
post it
* Using “1” instead of an “x” allows the columns to total automatically.
Injury
Skin disorder
Respiratorycondition
Poisoning
Hearing Loss
All other illnesses
Page       of      
(1) (2) (3) (4) (5) (6)
440-3353A (12/03)
1
OSHA Form 300 Previous Page OSHA Form 300 Next Page
OSHA Form 300
Previous

1/2

Next