MIOSHA Form 300 Template: Work-Related Injuries & Illnesses Log

MIOSHA Form 300 – Log of Work-Related Injuries and Illnesses Template

[Company / Establishment Name]

[Street Address]

[City, State (MI), ZIP Code]

[Industry Description]

MIOSHA 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 (MI), ZIP Code]

Industry / Business Description: [Short description, e.g., “Manufacturing – metal fabrication,” “Warehouse and distribution,” “Construction,” “Office – professional services,” etc.]

Contact Person for Recordkeeping Questions:

Name: [Full Name]

Title: [Title – e.g., Safety Manager, HR Manager, EHS Coordinator]

Phone: [Phone Number]

Email (optional): [Email Address]

2. General Instructions for Using This Log

• Keep a separate MIOSHA Form 300 log for each establishment that is expected to operate for at least one year.

• Use one “Log Entry” block (Section 3) for each MIOSHA-recordable work-related injury or illness. Assign case numbers in order (1, 2, 3, …).

• Use an incident report (MIOSHA Form 301 or an equivalent internal form) to document detailed information for each case listed in this log.

• Enter each recordable case on the log within the timeframe required after you learn that it is recordable.

• Update the number of days away from work and days of job transfer or restriction if they change, consistent with applicable counting rules.

• For “privacy concern” cases, list “Privacy Case” instead of the employee’s name and maintain a separate confidential list linking the case number to the employee’s identity.

Keep a separate MIOSHA Form 300 log for each establishment that is expected to operate for at least one year.

Use one “Log Entry” block (Section 3) for each MIOSHA-recordable work-related injury or illness. Assign case numbers in order (1, 2, 3, …).

Use an incident report (MIOSHA Form 301 or an equivalent internal form) to document detailed information for each case listed in this log.

Enter each recordable case on the log within the timeframe required after you learn that it is recordable.

Update the number of days away from work and days of job transfer or restriction if they change, consistent with applicable counting rules.

For “privacy concern” cases, list “Privacy Case” instead of the employee’s name and maintain a separate confidential list linking the case number to the employee’s identity.

3. MIOSHA 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 a privacy concern case, enter “Privacy Case” and record the name only on the 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: “Plant 1 – Assembly Line A,” “Warehouse – Loading Dock 2,” “Office – Room 210,” “Job site – roof area,” etc.]

3.2 Description of Injury or Illness

Briefly 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.

[Examples:

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

• “Laceration – right thumb from box cutter.”

• “Contusion – left knee from slip and fall on wet floor.”

• “Respiratory symptoms after inhalation of solvent fumes.”]

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

“Laceration – right thumb from box cutter.”

“Contusion – left knee from slip and fall on wet floor.”

“Respiratory symptoms after inhalation of solvent fumes.”]

3.3 Case Classification – Most Serious Outcome

Check only one category that reflects 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 recordable)

Death

Days away from work

Job transfer or restricted work

Other recordable case (no days away or restriction, but 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 this case:

• Injury

• Skin disorder

• Respiratory condition

• Poisoning

• Hearing loss

• Other illness

Injury

Skin disorder

Respiratory condition

Poisoning

Hearing loss

Other illness

3.6 Privacy Concern Case Indicator (If Applicable)

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

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

• Yes – “Privacy Case” is entered on this log, and a separate confidential list links the case number to the employee’s identity.

No – employee’s name appears on this log.

Yes – “Privacy Case” is entered on this log, and a separate confidential list links the case number to the employee’s identity.

3.7 Internal Notes (Optional)

Use this space for brief internal notes or cross-references (do not include confidential medical details):

[Examples: “Days away updated to 14 on 06/10,” “Case reclassified from restricted work to days away,” “See Incident Report #MI-IR-2025-004.”]

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 Concern Case List – Calendar Year: [20__]

For each privacy concern case, record:

• Case Number (from MIOSHA 300 log): [Case Number]

• Employee Identifier (name or internal ID): [Confidential – not posted]

• Optional Notes: [Short internal note, if needed]

Case Number (from MIOSHA 300 log): [Case Number]

Employee Identifier (name or internal ID): [Confidential – not posted]

Optional Notes: [Short internal note, if needed]

5. Annual Review and MIOSHA Form 300A Preparation

At the end of the calendar year:

1. Review all entries on this MIOSHA 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.

   • Number of cases in each injury/illness category.

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

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

5. Post the annual summary for the required period in a place where employee notices are normally displayed at this establishment.

Review all entries on this MIOSHA Form 300 log for accuracy and completeness.

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.

• Number of cases in each injury/illness category.

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.

Number of cases in each injury/illness category.

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

Have a company executive review and certify the annual summary as required by applicable rules.

Post the annual summary for the required period in a place where employee notices are normally displayed at this establishment.

6. Internal Certification of the Log

I certify that I have reviewed this MIOSHA-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 MIOSHA Form 300 log (paper or electronic) as part of your injury and illness recordkeeping file:

• MIOSHA Form 301 or equivalent incident report for each case

• 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 scene (if kept)

• Workers’ compensation claim forms or summaries

• Documentation of corrective actions or safety reviews

• Other supporting documents: [Describe]

MIOSHA Form 301 or equivalent incident report for each case

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 scene (if kept)

Workers’ compensation claim forms or summaries

Documentation of corrective actions or safety reviews

Other supporting documents: [Describe]