Transcription of Cal/OSHA Form 300A Appendix B Summary of Work-Related ...
1 Department of Indus rial RelationstDivision of occupational safety & HealthCal/ osha form 300a Appendix BYear 20 __Summary of Work-Related Injuries and IllnessesTotal number ofdeaths_____Total number ofcases with daysaway from work_____Number of CasesTotal number of days ofjob transfer or restriction_____Total number of daysaway from work_____Number of DaysPost this Summary page from February 1 t o April 30 of the year following the year covered by the establishments covered by CCR Title 8 Section 14300 must complete this Summary page, even if no Work-Related injuries or illnesses occurred during the year.
2 Remember to review the Log to verify that the entries are complete and accurate before completing this 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 youhad no cases, write 0. Employees, former employees, and their representatives have the right to review the Cal/OSHA form 300 in its entirety. They also have limited access to the Cal/OSHA form 301 or its equivalent. See CCR Title 8 Section , in Cal/OSHA s recordkeeping rule, for further details on the access provisions for these informationEmployment informationYour establishment name _____Street ___ _____ ___ ____ _____ _____ ___ _____City _____ State _____ ZIP _____Industry description ( )_____Standard Industrial Classification (SIC), if known ( )____ ____ ____ , Manufacture of motor truck , SIC 3715 Worksheet to estimate.
3 Annual average number of employees _____Total hours worked by all employees last year _____(If you don t have these figures, use the optionalSign hereKnowingly falsifying this document may result in a certify that I have examined this document and that to the best of myknowledge the entries are true, accurate, and executive TitlePhone Dat egaTotal number of.)
4 Musculoskeletal disorders _____Skin disorders _____Injuries _____Injury and Illness TypesRespiratory conditions _____Poisonings _____Hearing loss cases _____All other illnesses _____(G) (H) (I) (J)(K)(L)(M)(1)(2)(3)(4)(5)(6)(7)Total number ofcases with jobtransfer or restriction_____Total number ofother recordablecases_____
