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 transfer or restriction
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 FORMTEXT
0
0 FORMTEXT
0
0 FORMTEXT
0
0 FORMTEXT
0
0 FORMTEXT
0
days
0 FORMTEXT
0
days
0 FORMTEXT
0
0 FORMTEXT
0
0 FORMTEXT
0
0 FORMTEXT
0
0 FORMTEXT
0
0 FORMTEXT
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
Respiratory condition
Poisoning
Hearing Loss
All other illnesses
Page of
(1)
(2)
(3)
(4)
(5)
(6)
OSHA Form 300A
Summary of Work-Related Injuries and Illnesses
Year 20
Department of Consumer & Business Services
Oregon Occupational Safety &
Health Division (OR-OSHA)
Form approved OMB no. 1218-0176
All establishments covered by OAR 437-001-0700 must complete this Summary, 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, write the totals below, make sure you've added the entries from every page of the Log. If you haven't had any 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 DCBS Form 801 or its equivalent. See OAR 437-001-0700(20)
Establishment Information
Your establishment name
Street
City
State
ZIP
Industry description (e.g., Manufacturer of motor truck trailers)
Standard Industrial Classification (NAICS), if known (e.g.,336212)
Employment Information (If you don’t have these figures, see the worksheet on the back of this page to estimate.)
Annual average number of employees
Total hours worked by all employees last year
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:
/
/
Number of Cases
Total number of deaths
Total number of cases
with days away from work
Total number of cases with job transfer or restriction
Total number of
other recordable cases
(G)
(H)
(I)
(J)
Number of Days
Total number of days away from work
Total number of days
of job transfer or restriction
(K)
(L)
Injury and Illness Types
Total number of…
(M)
(1) Injuries
(4) Poisonings
(2) Skin disorders
(5) Hearing Loss
(3) Respiratory conditions
(6) All other illnesses
Keep this Summary posted from February 1 to April 30 of the year following the year covered by this form.
440-3353B (11/01)
(OR-OSHA/COM)
2
1
440-3353A (12/03)