Osha's Form 300a - Free Download
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Osha's Form 300a
Osha
U.S. Department of Labor
Occupational Safety and Health Administration
OSHA’s Form 300A (Rev. 01/2004)
Year 20__ __
Summary of Work-Related Injuries and Illnesses
Form approved OMB no. 1218-0176
Total number of
deaths
__________________
Total number of
cases with days
away from work
__________________
Number of Cases
Total number of days away
from work
___________
Total number of days of job
transfer or restriction
___________
Number of Days
Post this Summary page from February 1 to April 30 of the year following the year covered by the form.
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.
Establishment information
Employment information
Your establishment name
__________________________________________
Street _________________________ _______
City ____________________________ State ______ ZIP _________
Industry description ( )
_______________________________________________________
Standard Industrial Classification (SIC), if known ( )
____ ____ ____ ____
North American Industrial Classification (NAICS), if known (e.g., 336212)
e.g., Manufacture of motor truck trailers
e.g., 3715
(I ee the
Worksheet on the back of this page to estimate.)
_____________________
OR
____ ____ ____ ____ ____ ____
Annual average number of employees ______________
Total hours worked by all employees last year ______________
f you don’t have these figures, s
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.
___________________________________________________________
___________________________________________________________
Company executive Title
Phone Date
( ) - / /
Public reporting burden for this collection of information is estimated to average 50 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.
Total number of . . .
Skin disorders ______
Respiratory conditions ______
Injuries ______
Injury and Illness Types
Poisonings ______
Hearing loss
All other illnesses ______
______
(G) (H) (I) (J)
(K) (L)
(M)
(1)
(2)
(3)
(4)
(5)
(6)
Total number of
cases with job
transfer or restriction
__________________
Total number of
other recordable
cases
__________________
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