Cal/OSHA Form 300-Log of Work-Related Injuries …

1 ____ ____ ____ ____ ____ ____Department of Industrial RelationsDivision of Occupational Safety and HealthCal/OSHA Form 300 (Rev. 7/2007) Appendix AYear 20__ __Log of Work-Related Injuries and IllnessesYou must 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. You must also record significant Work-Related Injuries and illnesses that are diagnosed by a physician or licensed healthcare professional. You must also record Work-Related Injuries and illnesses that meet any of the specific recording criteria listed in CCR Title 8 Section through Feel free touse two lines for a single case if you need to. You must complete an Injury and Illness Incident Report ( Cal/OSHA Form 301) or equivalent form for each injury or illness recorded on thisform.

2 If you re not sure whether a case is recordable, call your local Cal/OSHA office for ____ of ____Skin disorderRespiratoryconditionP oisoningHearing losssBe sure to transfer these totals to the Summary page (Form 300A) before you post totalsEstablishment name _____City _____ State _____InjuryEnter the number ofdays the injured orill worker was:Check the Injury column orchoose one type of illness:Using these four categories, check ONLYthe most serious result for each case:month/daymonth/daymonth/daymonth/da ymonth/daymonth/daymonth/daymonth/daymon th/daymonth/daymonth/daymonth/daymonth/d ayIdentify the personDescribe the caseClassify the caseCase Employee s name Job title Date of injury Where the event occurred Describe injury or illness, parts of body affected,of illness or made person illno. or onset and object/substance that directly injured( )()().

3 , , Loading dock north , Second degree burns on right forearm from acetylene torch_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

4 ____ ____days daysdays daysdays daysdays daysdays daysdays daysdays daysdays daysdays daysdays daysdays daysdays daysdays days(A) (B) (C) (D) (E) (F)(M)(K) (L) (1) (2) (3) (4) (5) (6)Skin disorderRespiratoryconditionP oisoningHearing lossInjury (G)(H)(I)(J)DeathDays awayfrom workOther record-able casesJob transferor restrictionAttention: 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 usedfor occupational safety and health CCR Title 8 (b)(6)-(10)(1) (2) (3) (4) (5) (6)All other IllnessesAll otherIllnesses