OSHA Form 301

• Case No.

• Employee Name (Optional)

• Establishment name

• Conducted on

  Date

• Prepared by

Information about the employee

• Full name

• Address

• Date of birth

  Date

• Date hired

  Date

• Gender

  Male

  Female

Information about the physician or other health care professional

• Name of physician or other health care professional

• Was treatment given away from the worksite?

  Yes

  No

• Address where treatment was given

• Was employee treated in an emergency room?

  Yes

  No

• Was employee hospitalized overnight as an in-patient?

  Yes

  No

Information about the case

• Case number from the log

• Date of injury or illness

  Date

• Time employee began work

  Date

• Estimated time of event (leave blank if time cannot be determined)

  Date

• What was the employee doing before the incident occurred? Describe the activity, as well as the tools, equipment or material the employee was using.

• What happened? Tell us how the the injury occurred.

• Type of incident

  Select Injury Skin disorder Respiratory condition Poisoning Hearing loss Other illnesses

  • Injury
  • Skin disorder
  • Respiratory condition
  • Poisoning
  • Hearing loss
  • Other illnesses

• Enter type of incident

• Describe the injury or illness? Tell us the part of the body that was affected and how it was affected

• What object or substance directly harmed the employee?

• Upload photos of the incident

  Media

• Did the employee die?

  Yes

  No

• Date of death

  Date

Completion

• Observations and comments

• Full Name and Signature of Record Keeper

  Sign