Title Page
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Conducted on
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Prepared by
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Location
Number of Cases
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Total number of deaths (G)
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Total number of cases with days away from work (H)
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Total number of cases with job transfer or restriction (I)
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Total number of other recordable cases (J)
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Number of Days
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Total number of days away from work (K)
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Total number of days of job transfer or restriction (L)
Injury and Illness Types
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Total number of Injury
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Total number of Skin Disorder
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Total number of Respiratory Condition
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Total number of Poisoning
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Total number of Hearing Loss
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Total number of All Other Illnesses
Establishment Information
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Your establishment name
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Address
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Industry description
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Standard Industrial Classification (SIC) if known
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North American Industrial Classification (NAICS) if known
Employment Information
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Annual average number of employees
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Total hours worked by all employees last year
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Company executive
