Title Page
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Site conducted
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Employee Name
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Reported Date and Time of Injury or Illness
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Shift Reported on
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Reported how many hours since the start of shift
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Prepared by
OSHA 300 and 301
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Type of Incident
- Injury
- Skin disorder
- Respiratory condition
- Poisoning
- Hearing loss
- Other illnesses
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What was Injured?
- Hand
- Back
- Arm
- Foot
- Leg
- Face
- Abdominal Area
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Type of Illness
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Description of Injury or Illness, events leading up to it, and immediate actions taken.
Injury/Illness Details
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Type of Injury/Illness
- Abrasion
- Amputation
- Bruise
- Chemical Burn
- Chipped Tooth
- Contusion
- Electrical Burn
- Electrocution
- Fracture
- Hearing loss
- Laceration
- Poisoning
- Puncture
- Radiation Burn
- Respiratory Condition
- Skin Disorder
- Sprain
- Thermal Burn
- Other
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Body Part
- Abdomen
- Ankle
- Arm
- Back
- Buttocks
- Cardio System
- Chest/Ribs
- Ear
- Elbow
- Eye
- Face
- Fingers
- Foot/Ankle
- Groin
- Hand
- Hand/Wrist
- Head
- Hip
- Internal Body
- Jaw
- Knee
- Leg
- Leg/Knee/Hip
- Mouth
- Neck
- Nervous System
- Nose
- Pelvis
- Respiratory System
- Shoulder
- Teeth
- Toe
- Trunk
- Wrist
- Other
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Left or right
- Left
- Right
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Accident Type
- Contact with electricity or an electric discharge
- Contact with moving machinery or material being machined
- Drowned or asphyxiated
- Exposed to fire/explosion
- Exposed to, or in contact with, a harmful substance
- Fell from a height
- Hit by a moving vehicle
- Hit by a moving, flying, or falling object
- Hit by something fixed or stationary
- Injured by an animal
- injured while handling, lifting, or carrying
- Injured while working at a computer
- Physically assaulted by a person
- Slipped, tripped, or fell on the same level
- Trapped by something collapsing
- Other
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Accident Agent
- Animal/inspect
- Building/Structures
- Chair/Desk (office furniture)
- Chemical
- Compressed Gas Container
- Container (box, barrel, bag)
- Conveyor (belt/screw)
- Conveyor/Elec. / Hoist
- Drum
- Dust/Fume/Particles
- Electrical Apparatus
- Equipment/Apparatus (Fork Truck)
- Flammables
- Floor
- Fuel (gas, diesel)
- Glass
- Ground/Roadway
- Hand Tool
- Hot Surface
- Ice, Snow, Wind
- Knife
- Ladder/Scaffold
- Machine
- Noise
- Power Tool
- Stairway/Stairs/Ramp
- Tote
- Trash
- Vehicle
- Water/Stream
- Working Surface
- Other
Safe Work Practices
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Was PPE Worn?
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PPE Worn
- Chemical Apron
- Chemical Gloves
- Chemical Goggles/Face Shield
- FR Gloves
- Cotton Gloves
- Fall Protection
- FRC 2112 and CAT 2 Certified
- Fire Retardant Clothing
- Hard Hat
- Hearing Protection
- Impact Goggles/Face Shield
- Leather Gloves
- Neoprene Boots
- Personal Monitor
- Reflective or High Visibility Clothing
- Respirator
- Safety Glasses
- Non FR Raingear
- Raingear meeting ASTM F2733 Certification
- Face Shield
- Safety Shoes
- Steel Toed Boots
- Welding Helmet/Shield
- Other
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Describe PPE Worn
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OSHA Recordable?
OSHA 300 Log of Work-Related Injuries and Illnesses
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Job title
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Date of injury or onset of illness
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Where the event occurred
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Type of incident
- Injury
- Skin disorder
- Respiratory condition
- Poisoning
- Hearing loss
- Other illnesses
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Describe injury or illness, parts of body affected, and object/substance that directly injured or made person ill. (Add Photo of Injuries)
Classification
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Classify the case. Check only one box for each case based on the most serious outcome for that case:
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Please specify
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No. of days the injured or ill worker was away from work
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Date Classification Ended
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Please specify
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No. of days the injured or ill worker was away from work
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Date Classification Ended
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Please specify
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No. of days the injured or ill worker was on a job transfer or restriction
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Date Classification Ended
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Create Action for 30 days to review Recordable Classification
OSHA 301 Information
Information about the employee
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Full name
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Address
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Date of birth
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Date hired
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Gender
Information about the physician or other health care professional
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Name of physician or other health care professional
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Was treatment given away from the worksite?
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Address where treatment was given
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Was employee treated in an emergency room?
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Was employee hospitalized overnight as an in-patient?
Information about the case
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Date of injury or illness
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Time employee began work
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Estimated time of event (leave blank if time cannot be determined)
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What was the employee doing before the incident occurred? Describe the activity, as well as the tools, equipment or material the employee was using.
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What happened? Tell us how the the injury occurred.
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Type of incident
- Injury
- Skin disorder
- Respiratory condition
- Poisoning
- Hearing loss
- Other illnesses
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Enter type of incident
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Describe the injury or illness? Tell us the part of the body that was affected and how it was affected
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What object or substance directly harmed the employee?
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Did the employee die?
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Date of death
Root Cause Analysis
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Explain the problem to be solved. State the problem in objective terms and do not include any assumed causes of or solutions to the problem.
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Good example: There is a pool of oil on the floor measuring 2 feet wide by 1/4 inch deep vWhy 3?
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Poor Example: The forklift leaked a lot of oil on the floor because of a clogged filter
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Problem:
Why 1?
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Document the immediate cause of the symptom observed and the type of waste, then create actions for the countermeasures necessary to eliminate the cause
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Example - Symptom 1: Why is the oil on the floor? Cause 1: it leaked from the forklift. Countermeasure 1: Clean up the oil
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What is the observed symptom of the problem?
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Type of Waste
- Defects
- Over Production
- Waiting
- Non-Utilized Employee Talent
- Transportation
- Inventory
- Motion
- Extra Processing
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Countermeasures
Why 2?
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Document the immediate cause of symptom observed and the type of waste, then create actions for the countermeasures necessary to eliminate the cause
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Example - Symptom 2: Why did the oil leak from the forklift? Cause 2: A gasket dried out. Countermeasure 2: Replace the gasket
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What is the cause of the symptom?
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Type of Waste
- Defects
- Over Production
- Waiting
- Non-Utilized Employee Talent
- Transportation
- Inventory
- Motion
- Extra Processing
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Countermeasures
Why 3?
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Document the immediate cause of the symptom observed and the type of waste, then create actions for the countermeasures necessary to eliminate the cause
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What is the cause of the symptom?
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Type of Waste
- Defects
- Over Production
- Waiting
- Non-Utilized Employee Talent
- Transportation
- Inventory
- Motion
- Extra Processing
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Countermeasures
Why 4?
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Document the immediate cause of the symptom observed and the type of waste, then create actions for the countermeasures necessary to eliminate the cause
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What is the cause of the symptom?
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Type of Waste
- Defects
- Over Production
- Waiting
- Non-Utilized Employee Talent
- Transportation
- Inventory
- Motion
- Extra Processing
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Countermeasures
Why 5?
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Document the immediate cause of the symptom observed and the type of waste, then create actions for the countermeasures necessary to eliminate the cause
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What is the cause of the symptom?
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Type of Waste
- Defects
- Over Production
- Waiting
- Non-Utilized Employee Talent
- Transportation
- Inventory
- Motion
- Extra Processing
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Countermeasures
Additional "Why's?"
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Document the immediate cause of the symptom observed and the type of waste, then create actions for the countermeasures necessary to eliminate the cause
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What is the cause of the symptom?
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Type of Waste
- Defects
- Over Production
- Waiting
- Non-Utilized Employee Talent
- Transportation
- Inventory
- Motion
- Extra Processing
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Countermeasures
Completion
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Observations and comments
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Full Name and Signature of Record Keeper
