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

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.

2 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. 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.

3 Month/daymonth/daymonth/daymonth/daymont h/daymonth/daymonth/daymonth/daymonth/da ymonth/daymonth/daymonth/daymonth/dayIde ntify 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( )()().

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

5 _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ____ ____days daysdays daysdays daysdays daysdays daysdays daysdays daysdays daysdays daysdays daysdays daysdays daysdays days(A) (B) (C) (D) (E) (F)(M)(K)

6 (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