Free template
Cal/OSHA Form 300A – Summary of Work-Related Injuries and Illnesses Template
Summarize your annual Cal/OSHA work-related injury and illness data in a clear, compliant format for posting and recordkeeping.
Downloaded 2987 times
Cal/OSHA Form 300A – Summary of Work-Related Injuries and Illnesses Template
Download template
Cal/OSHA Form 300A – Summary of Work-Related Injuries and Illnesses Template
[Company / Establishment Name]
[Street Address]
[City, State, ZIP Code]
[Industry Description]
1. Year and Establishment Information
Calendar Year Covered by This Summary: [Year]
Establishment Name: [Site / Facility Name]
Address of Establishment: [Street Address]
City: [City]
State: [CA]
ZIP Code: [ZIP Code]
Industry / Business Description: [Short description, e.g., “Warehouse and distribution,” “Construction,” “Manufacturing,” “Office – professional services,” etc.]
NAICS Code (if known): [Code]
Average Number of Employees During the Year: [Number]
Total Hours Worked by All Employees Last Year: [Total hours worked by all employees at this establishment]
2. Summary of Cal/OSHA-Recordable Cases
Use totals from your Cal/OSHA Form 300 log for the same calendar year. Enter “0” in any category where no cases occurred.
2.1 Number of Cases
Total number of:
Deaths: [Number]
Cases with days away from work: [Number]
Cases with job transfer or restriction (but no days away): [Number]
Other recordable cases (no days away or restriction, but recordable): [Number]
2.2 Number of Days
Total number of:
Days away from work: [Number of calendar days]
Days of job transfer or restriction: [Number of calendar days]
2.3 Injury and Illness Types
Total number of cases in each category:
Injuries: [Number]
Skin disorders: [Number]
Respiratory conditions: [Number]
Poisonings: [Number]
Hearing loss: [Number]
All other illnesses: [Number]
3. Establishment Contact for This Summary
Contact Person for More Information About This Summary:
Name: [Full Name]
Title: [Title – e.g., Safety Manager, HR Manager, EHS Coordinator]
Phone: [Phone Number]
Email (optional): [Email Address]
4. Certification by Company Executive
A company executive must review the year’s Cal/OSHA injury and illness records and certify that this summary is true and complete, based on the Cal/OSHA Form 300 log for this establishment.
I certify that I have examined this Cal/OSHA-style summary of work-related injuries and illnesses for the calendar year indicated above and that, to the best of my knowledge, the entries are true, accurate, and complete.
Name of Certifying Official: [Full Name]
Title (check or describe):
Owner of the company (if a sole proprietorship or partnership)
Corporate officer
Highest ranking company official working at this establishment
Immediate supervisor of the highest ranking company official working at this establishment
Other (describe): [Description]
Signature of Certifying Official: _______________________________
Date Signed: [MM/DD/YYYY]
5. Posting Information
Date Summary Prepared: [MM/DD/YYYY]
Required Posting Period (adjust per current Cal/OSHA requirements and internal policy):
From: [MM/DD/YYYY]
To: [MM/DD/YYYY]
Location(s) Where This Summary Will Be Posted (for employees to see):
[Examples: “Main break room bulletin board,” “Entrance to production area,” “Time clock area,” etc.]
Name or Role of Person Responsible for Posting and Removing Summary:
[Name / Title]
6. Recordkeeping and Retention Notes
Recordkeeping Reminder:
Keep this Cal/OSHA 300A-style summary, your Cal/OSHA Form 300 log, and incident reports (Form 301 or equivalents) for at least the minimum number of years required by Cal/OSHA and company policy.
During the retention period, you may need to update your Cal/OSHA Form 300 log if the status or outcome of a case changes (for example, additional days away from work).
Maintain records in a secure but accessible format (paper or electronic) so they can be reviewed during inspections, audits, or internal safety reviews.
Internal Notes (optional):
[Use this area for internal remarks, such as “Totals checked against Cal/OSHA 300 log on [date],” “Summary revised after reclassification of Case #[X],” or references to internal safety committee reviews.]
7. Attachments Checklist (Internal Use)
You may keep the following documents with this summary as part of your Cal/OSHA recordkeeping file:
Cal/OSHA Form 300 log for this calendar year
Cal/OSHA Form 301 or equivalent incident reports for each recordable case
Internal accident / incident investigation reports
Workers’ compensation claim summaries or reports
Safety committee or management review notes related to this year’s cases
Correspondence with Cal/OSHA or other authorities about recorded cases
Other supporting documents: [Describe]
Flash deal
Flash deal
Today
Today
No time to fill it up? Generate your custom agreement with AI Lawyer in seconds
What’s Included
Legal Research
Legal Research
Legal Research
Contract Drafting
Contract Drafting
Contract Drafting
Document Review
Document Review
Document Review
Risk Analytics
Risk Analytics
Risk Analytics
Citation Verification
Citation Verification
Citation Verification
Easy-to-understand jargon
Easy-to-understand jargon
Easy-to-understand jargon
Details
Learn more about
Cal/OSHA Form 300A – Summary of Work-Related Injuries and Illnesses Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
CAL/OSHA FORM 300A SUMMARY TEMPLATE FAQ
What is the Cal/OSHA Form 300A Summary?
Cal/OSHA Form 300A is the annual summary of work-related injuries and illnesses for a specific calendar year. It uses totals from your Cal/OSHA Form 300 log and shows the number of recordable cases, days away from work, restricted or transferred work days, and types of injuries and illnesses for the year, along with basic establishment information.
Who must prepare and post a Cal/OSHA 300A-style summary?
Most California employers who are required to keep Cal/OSHA injury and illness records must complete an annual summary for each recordable establishment. The summary is typically prepared at the end of the calendar year and posted in a visible location at the workplace for employees to review, even if there were zero recordable cases. Some small or low-hazard employers may be exempt, so you should always confirm your status under current Cal/OSHA rules.
What information goes into a Cal/OSHA Form 300A summary?
A Cal/OSHA 300A-style summary usually includes: the calendar year, establishment name and address, industry description, average number of employees, total hours worked, total number of cases by classification (death, days away from work, job transfer/restriction, other recordable), total days away and restricted/transfer days, and total number of injuries and illness types. A company executive then certifies the summary.
Does the Cal/OSHA 300A summary replace the full Cal/OSHA Form 300 log?
No. The Cal/OSHA 300A summary is a high-level overview. It does not replace your Cal/OSHA Form 300 log or detailed incident reports (such as Form 301 or internal equivalents). You should keep the log and supporting records on file for the required retention period, even after the posting period for the summary ends.
Is this Cal/OSHA Form 300A template legal advice?
No. This Cal/OSHA Form 300A – Summary of Work-Related Injuries and Illnesses Template is a general drafting aid to help you organize information you already have. It does not interpret Cal/OSHA regulations, decide which cases are recordable, or guarantee compliance. For questions about California recordkeeping requirements, reporting rules, or posting obligations, consult official Cal/OSHA guidance or a qualified safety/HR professional or attorney.
How can AI Lawyer help with Cal/OSHA injury and illness summaries?
AI Lawyer can help you format totals from your Cal/OSHA Form 300 log into a clean summary using this template and adjust the wording to match your internal policies. You still provide the actual numbers, check their accuracy, and make final compliance decisions. Any AI-generated content is for document organization only and is not legal or safety advice.
Similar templates
Other templates from
Employment Legal Templates
Money back guarantee
Free trial
Cancel anytime
AI Lawyer protects
your rights and wallet
Money back guarantee
Free trial
Cancel anytime
AI Lawyer protects
your rights and wallet
Money back guarantee
Free trial
Cancel anytime
AI Lawyer protects
your rights and wallet
Money back guarantee
Free trial
Cancel anytime