Cal/OSHA Form 300 – Log of Work-Related Injuries and Illnesses Template

[Company / Establishment Name]
[Street Address]
[City, State, ZIP Code]
[Industry Description]

Cal/OSHA Form 300 – Log of Work-Related Injuries and Illnesses
Year Covered by This Log: [20__]

1. Establishment Information

Establishment Name: [Name of physical location or site]
Address of Establishment: [Street, City, State, ZIP Code]

Industry / Business Description: [Short description, e.g., “warehouse and distribution,” “food service,” “office – professional services,” etc.]

Contact Person for Recordkeeping Questions:
Name: [Full Name]
Title: [Title – e.g., Safety Manager, HR Manager]
Phone: [Phone Number]
Email (optional): [Email Address]

2. General Instructions for Using This Log

• Keep a separate Cal/OSHA Form 300 log for each establishment that is expected to operate for a year or more.

• Use one “Log Entry” (Section 3) for each Cal/OSHA-recordable case. Assign case numbers in order (1, 2, 3, …).

• Use an incident report (Cal/OSHA Form 301 or an equivalent internal form) to capture detailed information for each case listed here.

• Enter or update each recordable case on the log within the time frame required by Cal/OSHA after you learn that the case is recordable.

• Update days away from work and restricted/transfer days if they change later, in line with the counting rules that apply to your workplace.

• Do not list names for qualifying “privacy concern” cases; use “Privacy Case” and maintain a separate confidential list.

3. Cal/OSHA 300 Log Entry Template

(Repeat this block for each recordable case.)

Log Entry – Case [Case Number]

3.1 Basic Case Information

Case Number: [Sequential case number for this calendar year]

Employee Name: [First, Middle, Last]
(If this is a privacy concern case, enter “Privacy Case” here and keep a separate confidential list.)

Employee Job Title: [Job title at time of incident]

Date of Injury or Onset of Illness: [MM/DD/YYYY]

Where the Event Occurred (work area or location):
[Example: “Warehouse – Loading Dock B,” “Kitchen – prep area,” “Office – Room 210,” “Construction site – roof area,” etc.]

3.2 Description of Injury or Illness

Describe the injury or illness, the part(s) of the body affected, and the object or substance that directly injured or made the employee ill. Keep this short but specific.

[Examples:

• “Sprain – lower back while lifting box from pallet to conveyor.”

• “Laceration – left index finger from box cutter.”

• “Contusion – right hip and elbow after slip and fall on wet floor near entrance.”

• “Respiratory symptoms after inhalation of cleaning chemical.”]

3.3 Case Classification – Most Serious Outcome

Check only one category to show the most serious outcome for this case:

• Death

• Days away from work

• Job transfer or restricted work

• Other recordable case (no days away or restriction, but still recordable)

3.4 Days Away from Work and Days of Job Transfer/Restriction

Number of calendar days away from work: [Number of days]

Number of calendar days of job transfer or restricted work: [Number of days]

3.5 Type of Case – Injury or Illness Category

Check the category that best describes the case:

• Injury

• Skin disorder

• Respiratory condition

• Poisoning

• Hearing loss

• Other illness

3.6 Privacy Case Indicator (If Applicable)

Is this case treated as a privacy concern case under applicable rules?

• No – employee’s name appears on the log.

• Yes – “Privacy Case” appears on the log instead of the name; details and identity are kept in a separate confidential file.

3.7 Internal Notes (Optional)

Use this space for brief internal notes such as updates or cross-references:

[Examples: “Days away updated to 10 on 05/15,” “Doctor released employee to light duty,” “See Incident Report #IR-2025-014 for full details.”]

4. Privacy Concern Case List (Confidential – Internal Use Only)

Use this section only if you have privacy concern cases. Keep it in a secure, confidential file separate from the posted log.

Privacy Case List for Calendar Year: [20__]

For each privacy case:

• Case Number (from Cal/OSHA 300 log): [Case Number]

• Employee Identifier (name or internal ID): [Confidential info – do not post]

• Notes (optional – e.g., “Privacy concern case per internal criteria.”)

5. Annual Review and Cal/OSHA Form 300A Preparation

At the close of the calendar year:

1. Review all entries on this Cal/OSHA Form 300 log for accuracy and completeness.

2. Confirm totals for:

   • Number of deaths.

   • Number of cases with days away from work.

   • Number of cases with job transfer or restriction.

   • Number of other recordable cases.

   • Total days away from work.

   • Total days of job transfer or restriction.

   • Total number of cases for each injury/illness category.

3. Use these totals to prepare the Cal/OSHA Form 300A – Annual Summary of Work-Related Injuries and Illnesses.

4. Have a company executive review and certify the annual summary as required.

5. Post the 300A summary during the required posting period at the establishment, in a place where employee notices are normally displayed.

6. Internal Certification of the Log

I certify that I have reviewed this Cal/OSHA-style Log of Work-Related Injuries and Illnesses for the year indicated, and that, to the best of my knowledge, it is a true and complete record of the recordable cases for this establishment.

Name of Certifying Official: [Full Name]
Title: [Title – e.g., Owner, Corporate Officer, Highest Ranking Official at This Establishment]

Signature: _______________________________

Date: [MM/DD/YYYY]

7. Attachments and Supporting Records Checklist

You may keep the following documents with this Cal/OSHA Form 300 log (paper or electronic):

• Cal/OSHA Form 301 or equivalent incident report for each case on the log

• Internal accident / incident investigation reports

• Medical or work-status notes related to the case (where appropriate and allowed)

• Employee and witness statements

• Photos or sketches of the incident area (if kept)

• Workers’ compensation claim records or summaries

• Any corrective action or safety review documentation

• Other supporting documents: [Describe]

Record Retention Reminder: Keep this log and all associated records for at least the minimum number of years required by Cal/OSHA and your internal policies, and be prepared to update it if case outcomes change during the retention period.