Summary of Work-Related Injuries and Illnesses

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OSHA’s Form 300A

Summary of Work-Related Injuries and Illnesses

All establishments covered by Part 1904 must complete this Summary page, even if no work-related injuries or illnesses occurred during the year. Remember to review the Log

to verify that the entries are complete and accurate before completing this summary. Using the Log, count the individual entries you made for each category, then write the totals below, making sure you’ve added the entries from every page of the Log. If you had no cases, write”0.”
Employees, former employees, and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access to the OSHA Form 301

or its equivalent. See 29 CFR Part 1904.35 in OSHA’s recordkeeping rule, for further details on the access provisions for these forms.

Total number of


Total number of

cases with days

away from work

Total number of

cases with job

transfer or restriction

Total number of

Other recordable










Total number of days of

job transfer or restriction

Total number of days

away from work





Total number of. . .


(1) Injuries


(4) Poisonings


(2) Skin disorders


(5) All other illnesses


(3) Respiratory conditions


Post this Summary page from February 1 to April 30 of the year following the year covered by the form.
Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review The instructions, search and gather the data needed, and

complete and review the collection of information. Persons are not required To respond to the collection of information unless it displays a currently valid OMB control number. If you have any

comments About these estimates or any other aspects of this data collection, contact: U.S. Department of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Avenue, NW, Washington,

DC 20210. Do not send the completed forms to this office.

Establishment Information
Your establishment name      
City       State NC ZIP  

Industry description (e.g. Manufacture of motor truck trailers)

Standard Industrial Classification (SIC), if known (e.g. SIC 3715)


Employment information (If you don’t have these figures, see the

Worksheet on the back of this page to estimate.)

Annual average number of employees      
Total hours worked by all employees last year      
Sign here
Knowingly falsifying this document may result in a fine.
I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete.

Company Executive Title

(   )       05/14/02

Phone Date

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