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.

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.”]

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)

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

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.

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]

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.

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]