Company: 


Address: 


City:    State:   Zip:


Phone: 

Full Name:

Email:

1.) Date of most recent injury/illness resulting in day(s) away from work: (mm/dd/yyyy)

Report all information below for current six month period only
(corresponds with period identified above)

2.) Average Number of Employees:


3.) Total Hours Worked (entire six month period, all employees):

Items 4, 5 and 6 are based on the Recordkeeping Requirements under the Occupational Safety & Health Act of 1970 (rev. 1/1/02). The columns listed below correspond to the columns in the OSHA 300 log.

4.) Number of Deaths (column G in OSHA 300 Log):


5.) Number of occupational injuries and/or illnesses resulting in days away from work
                                 (column H in OSHA 300 Log):


6.) Number of days away from work as a result of occupational injuries and/or illness
                                 (column K in OSHA 300 Log):


Note: If you report a death, injury or illness resulting in days away from work in the current six month period (item 4 or 5), the most recent date of the death, injury or illness must correspond with item 1.