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.
Please Record:
Information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid.
Significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional.
Work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12.
Reminders:
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.
Feel free to use two lines for a single case if you need to.
Complete the 5 steps for each case.
•
Identify the person
Case no.
Employee's Name
Job Title
Describe the case
Date of injury or onset of illness
Where the event occurred
e.g. Loading dock north end
Describe injury or 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
Classify the case
Category
Death
Days away form work
Job transfer or restriction
Other recordable cases