OSHA Form 301 for Reporting Incident

The filing of the report is at the discretion of the Job Supervisor. However, it is recommended that an injury report be filed for each reported injury incident, no matter the severity. It is better to file a report and not need it than to need a report and not have filed it.

IMPORTANT:

This form contains information relating to worker health and must be used in a manner that protects the confidentiality of workers to the extent possible while the information is being used for occupational safety and health purposes.

This is one of the first forms you must fill out when a recordable work-related injury or illness has occurred. Together with the Log of Work-Related Injuries and Illnesses and the accompanying Summary, these forms help to develop a picture of the extent and severity of work-related incidents.

Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out this form or an equivalent. Some state workers’ compensation, insurance, or other reports may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the information asked for on this form.

According to Public Law 91-596 and 29 CFR 1904, OSHA’s recordkeeping rule, you must keep this form on file for 5 years following the year to which it pertains.

OSHA Form 301
Injury and Illness Incident Report

SITE SUPERVISOR
Complete when a reportable incident has occurred.

PROJECT MANAGER
Copy to Project Binder, Copy to Accounting/Risk Management.

RISK MANAGER
File in Safety Compliance folder for minimum 5 years.

Completed by

Title

Email Address

Phone

Date

Information about the employee

Full Name

Street

City, ST ZIP

Date of Birth

Date Hired

Gender

Male Female

Information about the physician or other health care professional

Name of physician or other health care professional

If treatment was given away from the worksite, where was it given? (Facility, Street, City, ST, ZIP)

Was employee treated in an emergency room?

Yes No NA

Was employee hospitalized overnight as an in-patient?

Yes No NA

Information about the case

https://www.osha.gov/recordkeeping (Transfer the number from the Log after you record the case)

Case number from the log

Date of injury or illness

Time employee began work

Time of event

Check if time cannot be determined

Time cannot be determined

What was the employee doing just before the incident occured?

Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. “climbing a ladder while carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.”

What happened?

Tell us how the injury occurred. “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker developed soreness in wrist over time.”

What was the injury or illness?

Tell us the part of the body that was affected and how it was affected; be more specific than “hurt,” “pain,” or sore.” “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.”

What object or substance directly harmed the employee?

Example: "concrete floor"; "chlorine"; radial arm saw." If this question does not apply to the incident, leave it blank.

If the employee died, when did death occur?

Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.

Send to

Project Manager

Risk Manager

Copy to

When the “Send Report” button is selected, an email with all the information in this Report will be sent to the email addresses provided.