Transcription of 301 Incident Report
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301 Incident Report
Attention: This form contains information relating to OSHA's Form 301 employee health and must be used in a manner that protects the confidentiality of employees to the extent Injury and Illness Incident Report possible while the information is being used for occupational safety and health purposes. Department of Labor Occupational Safety and Health Administration Form approved OMB no. 1218-0176. Information about the employee Information about the case This Injury and Illness Incident Report is one of the 1) Full name _____ 10) Case number from the Log _____ (Transfer the case number from the Log after you record the case.). first forms you must fill out when a recordable work- related injury or illness has occurred. Together with 11) Date of injury or illness _____ / _____ / _____. 2) Street _____. the Log of Work-Related Injuries and Illnesses and the 12) Time employee began work _____ AM / PM. accompanying Summary, these forms help the employer and OSHA develop a picture of the extent City _____ State _____ ZIP _____ 13) Time of event _____ AM / PM 0 Check if time cannot be determined and severity of work-related incidents.
Information about the employee Information about the physician or other health care professional Full name Street City State ZIP Date of birth Date hired
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