Cal/OSHA Form 300 Appendix A "Log of Work-Related Injuries and Illnesses" - California

What Is Cal/OSHA Form 300 Appendix A?

This is a legal form that was released by the California Department of Industrial Relations - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2007;
  • The latest edition provided by the California Department of Industrial Relations;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Cal/OSHA Form 300 Appendix A by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations.

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Download Cal/OSHA Form 300 Appendix A "Log of Work-Related Injuries and Illnesses" - California

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Attention: This form contains information relating to employee health
and must be used in a manner that protects the confidentiality of
Cal/OSHA Form 300 (Rev. 7/2007)
Appendix A
Year 20__ __
employees to the extent possible while the information is being used
for occupational safety and health purposes.
Log of Work-Related Injuries and Illnesses
Department of Industrial Relations
See CCR Title 8 14300.29(b)(6)-(10)
Division of Occupational Safety and Health
You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer,
days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health
Establishment name ___________________________________________
care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in CCR Title 8 Section 14300.8 through 14300.12. Feel free to
use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (Cal/OSHA Form 301) or equivalent form for each injury or illness recorded on this
City ________________________________ State ___________________
form. If you’re not sure whether a case is recordable, call your local Cal/OSHA office for help.
Identify the person
Describe the case
Classify the case
Enter the number of
Using these four categories, check ONLY
Check the “Injury” column or
(A)
(B)
(C)
(D)
(E)
(F)
days the injured or
the most serious result for each case:
ill worker was:
choose one type of illness:
Case
Employee’s name
Job title
Date of injury
Where the event occurred
Describe injury or illness, parts of body affected,
(
e.g., Loading dock north end
)
(e.g
., Welder
)
no.
or onset
and object/substance that directly injured
(M)
Days away
of illness
or made person ill
Death
from work
On job
e.g., Second degree burns on right forearm from acetylene torch
(e.g. month/day)
Away from
(
)
Other record-
Job transfer
transfer or
work
or restriction
able cases
restriction
(G)
(H)
(I)
(J)
(K)
(L)
(1)
(2)
(3)
(4)
(5)
(6)
I
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month/day
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days
month/day
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____________________________ _____
days
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____________ __ _______
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______________________________
____________________ _____
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month/day
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____________ __ _______
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______________________________
____________________ _____
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days
days
month/day
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_____ ________________________
____________ __ _______
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______________________________
____________________ _____
days
days
month/day
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____________ __ _______
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_______________ _ ___
___________________
_______________________________ _____
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days
days
month/day
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_____ ________________________
____________ __ _______
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_______________ _ ___
______________________________
____________________ _____
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days
days
month/day
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I
I
I
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_____ ________________________
____________ __ _______
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_______________ _ ___
______________________________
____________________ _____
days
days
month/day
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_____ ________________________
____________ __ _______
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__________________
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___________________
_______________________________ _____
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days
days
month/day
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____
Page totals
Be sure to transfer these totals to the Summary page (Form 300A) before you post it.
(1)
(2)
(3)
(4)
(5)
(6)
Page ____ of ____
Attention: This form contains information relating to employee health
and must be used in a manner that protects the confidentiality of
Cal/OSHA Form 300 (Rev. 7/2007)
Appendix A
Year 20__ __
employees to the extent possible while the information is being used
for occupational safety and health purposes.
Log of Work-Related Injuries and Illnesses
Department of Industrial Relations
See CCR Title 8 14300.29(b)(6)-(10)
Division of Occupational Safety and Health
You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer,
days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health
Establishment name ___________________________________________
care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in CCR Title 8 Section 14300.8 through 14300.12. Feel free to
use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (Cal/OSHA Form 301) or equivalent form for each injury or illness recorded on this
City ________________________________ State ___________________
form. If you’re not sure whether a case is recordable, call your local Cal/OSHA office for help.
Identify the person
Describe the case
Classify the case
Enter the number of
Using these four categories, check ONLY
Check the “Injury” column or
(A)
(B)
(C)
(D)
(E)
(F)
days the injured or
the most serious result for each case:
ill worker was:
choose one type of illness:
Case
Employee’s name
Job title
Date of injury
Where the event occurred
Describe injury or illness, parts of body affected,
(
e.g., Loading dock north end
)
(e.g
., Welder
)
no.
or onset
and object/substance that directly injured
(M)
Days away
of illness
or made person ill
Death
from work
On job
e.g., Second degree burns on right forearm from acetylene torch
(e.g. month/day)
Away from
(
)
Other record-
Job transfer
transfer or
work
or restriction
able cases
restriction
(G)
(H)
(I)
(J)
(K)
(L)
(1)
(2)
(3)
(4)
(5)
(6)
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ _______
_______
__________________
____
___________________
_______________________________ _____
days
days
month/day
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ _______
_______
_______________ _ ___
________________________________
__________________ _____
____
____
days
days
month/day
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ _______
_______
_______________ _ ___
______________________
____________________________ _____
days
days
month/day
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ _______
_______
_______________ _ ___
______________________
____________________________ _____
days
days
month/day
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ _______
_______
_______________ _ ___
___________________
_______________________________ _____
____
____
days
days
month/day
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ _______
_______
_______________ _ ___
______________________________
____________________ _____
days
days
month/day
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ _______
_______
_______________ _ ___
______________________________
____________________ _____
____
____
days
days
month/day
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ _______
_______
_______________ _ ___
______________________________
____________________ _____
____
____
days
days
month/day
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ _______
_______
_______________ _ ___
______________________________
____________________ _____
days
days
month/day
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ _______
_______
_______________ _ ___
___________________
_______________________________ _____
____
____
days
days
month/day
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ _______
_______
_______________ _ ___
______________________________
____________________ _____
____
____
days
days
month/day
I
I
I
I
I
I
I
I
____
____
_____ ________________________
____________ __ _______
_______
_______________ _ ___
______________________________
____________________ _____
days
days
month/day
I
I
I
I
I
I
I
I
_____ ________________________
____________ __ _______
_______
__________________
____
___________________
_______________________________ _____
____
____
days
days
month/day
____
____
____
____
____
____
Page totals
Be sure to transfer these totals to the Summary page (Form 300A) before you post it.
(1)
(2)
(3)
(4)
(5)
(6)
Page ____ of ____