Information about the employee
OSHA’s Form 301
Injury and Illness Incident
Report [Incident #1]
This Injury and Illness Incident Report is one
of the first forms you must fill out when a
recordable work-related injury or illness has
occurred. Together with the Log of Work-
Related Injuries and Illnesses and the
accompanying Summary, these forms help
the employer and OSHA develop a picture
of the extent and severity of work-related
incidents.
Within 7 calendar days after you
receive information that a work-related
injury or illness has occurred, you must fill
out this form or an equivalent. Some state
workers’ compensation, insurance, or other
reports may be acceptable substitutes. To
be considered an equivalent form, any
substitute must contain all the information
asked for on this form.
According to Public Law 91-596 and 29
CFR 1904, OSHA’s recordkeeping rule, you
must keep this form on file for 5 years
following the year to which it pertains.
If you need additional copies of this
form, you may photocopy and use as many
as you need.
Completed by
Title
Phone ( ) - Date / /
Information about the case
1) Full name 10) Case number from the Log
2) Street (Transfer the case number from the Log after you record the case)
11) Date of injury or illness / /
City State Zip 12) Time employee began work AM/PM
3) Date of Birth / / 13) Time of event AM/PM
4) Date hired / / __ Check if time cannot be determined
14) What was the employee doing just before the incident
5) Male
occurred? Describe the activity, as well as the tools,
Female
equipment, or material the employee was using. Be specific.
Examples: “climbing a ladder while carrying roofing
Information about the physician
materials”; “spraying chlorine from hand sprayer”; “daily
or other healthcare professional computer key-entry.”
6) Name of physician or other healthcare
professional
15) What happened? Tell us how the injury occurred. Examples:
7) If treatment was given away from the “When ladder slipped on wet floor, worker fell 20 feet”;
worksite, where was it given? “Worker was sprayed with chlorine when gasket broke during
Facility replacement”; “Worker developed soreness in wrist over
time.”
Street
City State Zip 16) What was the injury or illness? Tell us the part of the body
that was affected and how it was affected; be more specific
than “hurt,” “pain,” or “sore.” Examples: “strained back”;
8) Was the employee treated in an emergency “Chemical burn, hand”; “carpal tunnel syndrome.”
room?
Yes
No
9) Was employee hospitalized overnight as an 17) What object or substance directly harmed the employee?
in-patient? Examples: “concrete floor”; “chlorine”; “radial arm saw.” If
this question does not apply to the incident, leave it blank.
Yes
No
18) If the employee died, when did death occur?
Date of death / /
 OSHA’s Form 301
Injury and Illness Incident Report [Incident
#2]
This Injury and Illness Incident Report is one of the first forms you
must fill out when a recordable work-related injury or illness has
occurred. Together with the Log of Work-Related Injuries and
Illnesses and the accompanying Summary, these forms help the
employer and OSHA develop a picture of the extent and severity
of work-related incidents.
Within 7 calendar days after you receive information that a
work-related injury or illness has occurred, you must fill out this
form or an equivalent. Some state workers’ compensation,
insurance, or other reports may be acceptable substitutes. To be
considered an equivalent form, any substitute must contain all the
information asked for on this form.
According to Public Law 91-596 and 29 CFR 1904, OSHA’s
recordkeeping rule, you must keep this form on file for 5 years
following the year to which it pertains.
If you need additional copies of this form, you may photocopy
and use as many as you need.

Completed by

Title

Phone ( ) - Date / /
Information about the No Information about the case
employee 10) Case number from the Log
(Transfer the case number from the Log after you record the case)
1) Full name 11) Date of injury or illness / /
2) Street 12) Time employee began work AM/PM
13) Time of event AM/PM
City State __ Check if time cannot be determined
Zip 14) What was the employee doing just before the incident
3) Date of Birth / / occurred? Describe the activity, as well as the tools,
4) Date hired / / equipment, or material the employee was using. Be specific.
5) Male Examples: “climbing a ladder while carrying roofing
Female materials”; “spraying chlorine from hand sprayer”; “daily
computer key-entry.”
Information about the
physician or other healthcare
professional 15) What happened? Tell us how the injury occurred. Examples:
“When ladder slipped on wet floor, worker fell 20 feet”;
6) Name of physician or other healthcare “Worker was sprayed with chlorine when gasket broke during
professional replacement”; “Worker developed soreness in wrist over
time.”
7) If treatment was given away from the
worksite, where was it given?
Facility
16) What was the injury or illness? Tell us the part of the body
that was affected and how it was affected; be more specific
Street than “hurt,” “pain,” or “sore.” Examples: “strained back”;
“Chemical burn, hand”; “carpal tunnel syndrome.”
City State
Zip

17) What object or substance directly harmed the employee?

8) Was the employee treated in an Examples: “concrete floor”; “chlorine”; “radial arm saw.” If
emergency room? this question does not apply to the incident, leave it blank.
Yes
No
9) Was employee hospitalized overnight
18) If the employee died, when did death occur?
as an in-patient?
Date of death / /
Yes

OSHA’s Form 301
Injury and Illness Incident
Report [Incident #3]
This Injury and Illness Incident Report is one
of the first forms you must fill out when a
recordable work-related injury or illness has
occurred. Together with the Log of Work-
Related Injuries and Illnesses and the
accompanying Summary, these forms help
the employer and OSHA develop a picture
of the extent and severity of work-related
incidents.
Within 7 calendar days after you
receive information that a work-related
injury or illness has occurred, you must fill
out this form or an equivalent. Some state
workers’ compensation, insurance, or other
reports may be acceptable substitutes. To
be considered an equivalent form, any
substitute must contain all the information
asked for on this form.
According to Public Law 91-596 and 29
CFR 1904, OSHA’s recordkeeping rule, you
must keep this form on file for 5 years
following the year to which it pertains.
If you need additional copies of this
form, you may photocopy and use as many
as you need.
Completed by
Title
Phone ( ) - Date / /
Information about the employee Information about the case
1) Full name 10) Case number from the Log
2) Street (Transfer the case number from the Log after you record the case)
11) Date of injury or illness / /
City State Zip 12) Time employee began work AM/PM
3) Date of Birth / / 13) Time of event AM/PM
4) Date hired / / __ Check if time cannot be determined
14) What was the employee doing just before the incident
5) Male
occurred? Describe the activity, as well as the tools,
Female
equipment, or material the employee was using. Be specific.
Examples: “climbing a ladder while carrying roofing
Information about the physician
materials”; “spraying chlorine from hand sprayer”; “daily
or other healthcare professional computer key-entry.”
6) Name of physician or other healthcare
professional
15) What happened? Tell us how the injury occurred. Examples:
7) If treatment was given away from the “When ladder slipped on wet floor, worker fell 20 feet”;
worksite, where was it given? “Worker was sprayed with chlorine when gasket broke during
Facility replacement”; “Worker developed soreness in wrist over
time.”
Street
City State Zip 16) What was the injury or illness? Tell us the part of the body
that was affected and how it was affected; be more specific
than “hurt,” “pain,” or “sore.” Examples: “strained back”;
8) Was the employee treated in an emergency “Chemical burn, hand”; “carpal tunnel syndrome.”
room?
Yes
No
9) Was employee hospitalized overnight as an 17) What object or substance directly harmed the employee?
in-patient? Examples: “concrete floor”; “chlorine”; “radial arm saw.” If
this question does not apply to the incident, leave it blank.
Yes
No
18) If the employee died, when did death occur?
Date of death / /
 OSHA’s Form 300
Log of Work-Related Injuries and Illnesses

Establishment Name_________________________________
City _____________________________ State ____________

Identify the Person Describe the case Classify the case

(M) Enter the
CHECK ONLY ONE box for each
number of days
(M) case based on the most serious
the injured or ill Check the “Injury” column or
outcome for that case:
worker was: choose one type of illness:
(A) (B) (C) (D) (E) (F) (G) (H) (I) (J) (K) (L)
Death Days Remained at Work Away On job
Case Employee’s Job Title Date of Where the Describe injury or illness, away from transfer
Job Other

Respiratory condition
no. Name (e.g., injury event parts of body affected, and from work or
Welder) Transfer recordable

All other illnesses

or occurred object/substance that work or cases restriction
onset (e.g., directly injured or made restriction

Skin disorder

Hearing loss
of Loading person ill

Poisoning
dock north (e.g., Second degree burns on
illness end) right forearm from acetylene

Injury
torch)

/
mon/day days days

/
mon/day days days

/
mon/day days days

/
mon/day days days

Page Totals→
(1) (2) (3) (4) (5) (6)
OSHA’s Form 300A
Summary of Work-Related Injuries and Illnesses Establishment information

Number of Cases Your establishment name

Street
Total Number Total number Total number Total number City State Zip
of deaths of cases with of cases with of other Industry description (e.g., Manufacture of motor truck trailers)
days away from job transfer or recordable
work restriction cases
Standard Industrial Classification (SIC), if known (e.g., 3715)

(G) (H) (I) (J)

Number of Days OR
North American Industrial Classification (NAICS), if known (e.g., 336212)
Total number of days away Total number of days of job
from work transfer or restriction
Employment Information
(If you don’t have these figures, see the Worksheet on the back of
(K) (L) this page to estimate.)
Annual average number of employees
Injury and Illness Types
Total hours worked by all employees last year
Total number of… (M) Sign Here
Knowingly falsifying this document may result in a fine.
(1) Injuries (4) Poisonings I certify that I have examined this document and that to the best of
my knowledge the entries are true, accurate, and complete.
(2) Skin
disorders (5) Hearing loss
Company Executive Title
(3) Respiratory (6) All other
conditions illnesses
Phone Date
 Calculating Injury and Illness Incidence Rates

Worksheet
Total number of Number of hours Total recordable case
injuries and illnesses worked by all employees rate

X 200,000 ÷ =

Number of entries in Number of hours

Column H + Column I worked by all employees DART incidence rate

X 200,000 ÷ =