Department of Indus rial Relationst Division of Occupational Safety & Health Cal/OSHA Form 300A (Rev. 7/2007) Appendix B Year 20 __ Annual Summary of ...
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Appendix B
Cal/OSHA Form 300A (Rev. 7/2007)
Year 20 _ _
Annual Summary of Work-Related Injuries and Illnesses All establishments covered by CCR Title 8 Section 14300 must complete this Annual Summary, even if 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 o f the Log. If you had no cases, write “0.” Employees, former employees, and their representatives have the right to review the Cal/OSHA Form 300 in its entirety. They also have limited access to the Cal/OSHA Form 301 or its equivalent. See CCR Title 8 Section 14300.35, in Cal/OSHA’s recordkeeping rule, for further details on the access provisions for these forms.
Department of Industrial Relations Division of Occupational Safety & Health
Establishment information Your establishment name _____________________________________________ Street ___ __ __ ___ ___ ____ __ ___ __ ______ ___ ___ __________________________ City __ ___ ___ __ ______________________________State ______ ZIP _________
Number of Cases Total number of deaths __________________
Total number of cases with days away from work __________________
(G)
Total number of cases with job transfer or restriction
Total number of other recordable cases
__________________
__________________
(H)
(I)
(J)
Industry description (e.g., Manufacture of motor truck trailers) _______________________________________________________ Standard Industrial Classification (SIC), if known (e.g., SIC 3715) ____ ____ ____ ____
Employment information (If you don’t have these figures, use the optional Worksheet to estimate.)
Number of Days
Total number of days away from work
Total number of days of job transfer or restriction
___________
___________
(K)
(L)
Annual average number of employees
______________
Total hours worked by all employees last year
______________
Sign here Knowingly falsifying this document may result in a fine.
Injury and Illness Types
I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete.
