OSHA’s Form 301 Injury and Illness Incident Report Department of Occupational Safety and Health Administration Form approved OMB no. 1218-0176 Information about the employee Information about the case Full name Case number from the Log (Transfer the case number from the Log after you record the case.) Date of injury or illness / / Street Time employee began work AM / PM City State ZIP 13) Time of event AM / PM Check if time cannot be determined Describe the activity, as well as the What was the employee doing just before the incident occurred? / / Date of birth tools, equipment, or material the employee was using. Be specific. a ladder while carrying Examples: “climbing / / Date hired roofing materials”; chlorine from hand sprayer”; computer key-entry.” “spraying “daily O 5) Male O Female Tell us how the injury occurred. ladder slipped on wet floor, worker fell 20 What happened? Examples: “When Information about the physician or other health care feet”; was sprayed with chlorine when gasket broke during replacement”; developed “Worker “Worker professional soreness in wrist over time.” Name of physician or other health care professional If treatment was given away from the worksite, where was it given? Tell us the part of the body that was affected and how it was affected; be more What was the injury or illness? specific than or sore.” back”; burn, hand”; tunnel Examples: “hurt,” “pain,” “strained “chemical “carpal Facility syndrome.” Street City State ZIP floor”; What object or substance directly harmed the employee? Examples: “concrete “chlorine”; “radial Was employee treated in an emergency room? arm saw.” If this question does not apply to the incident, leave it blank. O Yes O No 9) Was employee hospitalized overnight as an in-patient? O Yes O No If the employee died, when did death occur? Date of death / /
OSHA’s Form 301 Injury and Illness Incident Report Department of Occupational Safety and Health Administration Information about the employee Information about the case Form approved OMB no. 1218-0176 Full name Street Case number from the Log (Transfer the case number from the Log after you record the case.) Date of injury or illness / / Time employee began work City State ZIP 13) Time of event AM / PM AM / PM Check if time cannot be determined Date of birth / / Date hired / / 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.” 5) O O Male Female Information about the physician or other health care professional Name of physician or other health care professional If treatment was given away from the worksite, where was it given? Facility Street City State ZIP Was employee treated in an emergency room? What happened? Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker developed soreness in wrist over time.” 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.” 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. O Yes O No 9) Was employee hospitalized overnight as an in-patient? O Yes O No If the employee died, when did death occur? Date of death / /
OSHA%20300%20Form.docx