RHL Companies -OSHA's Form 300A

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• All establishments covered by Part 1904 must complete this Summary page, even of 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 record keeping rule, for further details on the access provisions for these forms.

Number of Cases

• Total Number of Deaths:

• Total Number of Cases with Days Away From Work:

• Total Number of Other Recordable Cases:

Number of Days

• Total Number of Days Away From Work:

• Total Number of Days of Job Transfer or Restriction:

Injury and Illness Types

• Total Number of........

• Injuries

• Skin Disorders

• Respiratory Conditions

• Poisonings

• Hearing Loss

• All Other Illnesses

Establishment Information

• Your Establishment Name:

• Address:
  Address

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

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

• OR

• North American Industrial Classification (NAICS), if known (e.g., 336212)

Employment Information

• Annual average number of employees:

• Total hours worked by all employees last year:

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• 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.

  Sign

• Title

• Phone:

• Select date

  Date