OSHA 301 – Incident Report – Energy Star Lighting Electric Inc

OSHA Form 301

Injury and Illness Incident Report

Attention: 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 used for occupational safety and health purposes.

Legal Notice

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 recordable work-related injury or illness has occurred, you must fill out this form. According to Public Law 91-596 and 29 CFR 1904, OSHA’s recordkeeping rule, we must keep this form on file for 5 years following the year to which it pertains.

Completed by *

Title *

Phone *

Date *

Information about the employee

1) Full Name *

2) Address *

Country

City

State

Zip code

3) Date of birth *

4) Date Hired *

5) Gender *

Information about the physician or other healthcare professional

6) Name of physician or other healthcare professional

7) If treatment was given away from the worksite, where was it given?

Facility

Address

Apt, suite, etc.

Country

City

State

Zip code

8) Was employee treated in an emergency room?

Yes

9) Was employee hospitalized overnight as an in-patient?

Yes

Information about the case

10) Case number from the log (if known at the time of filing)

11) Date of injury or illness *

12) Time employee began work *

13) Time of event

Check if time cannot be determined

Please do not include any personally identifiable information (PII) pertaining to worker(s) involved in the incident (e.g., no names, phone numbers, or SSNs) in the following fields.

14) What was the employee doing just before the incident occurred? *

Describe the activity, as well as the tools, equipment or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry."

15) What happened? *

Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement"; "Worker developed soreness in wrist over time."

16) What was the injury or illness? *

Tell us the part of the body that was affected and how it was affected. Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."

17) What object or substance directly harmed the employee?

Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank.

18) If the employee died, when did death occur?

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