Free template
MIOSHA Form 300 – Log of Work-Related Injuries and Illnesses Template
Maintain a clear Michigan-specific log of work-related injuries and illnesses for compliance, audits, and internal safety tracking.
Downloaded 3527 times
Download template
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:
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.
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]
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
MIOSHA Form 300 – Log 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.
MIOSHA FORM 300 – LOG OF WORK-RELATED INJURIES AND ILLNESSES TEMPLATE FAQ
What is MIOSHA Form 300 – Log of Work-Related Injuries and Illnesses?
MIOSHA Form 300 is Michigan’s version of the “Log of Work-Related Injuries and Illnesses.” Covered employers use it to record each work-related injury or illness that meets the criteria for being MIOSHA-recordable during a calendar year, including who was injured, what happened, how serious the outcome was, and how many days of work were affected.
Who is required to maintain a MIOSHA 300 log in Michigan?
Most Michigan employers with a certain number of employees and that are not in a fully exempt low-hazard industry must maintain injury and illness records, including a log (Form 300), an annual summary (Form 300A), and incident reports (Form 301 or equivalent). Some small or low-hazard employers may be partially exempt. Employers should review current MIOSHA guidance or consult a qualified safety/HR professional to confirm their obligations.
What information should be recorded on the MIOSHA Form 300 log?
For each recordable case, you typically record: the employee’s name and job title, the date of injury or illness onset, where the event occurred, a brief description of what happened and which body parts were affected, the most serious result of the case (death, days away from work, restricted work/transfer, or other recordable), the number of days away from work, and the number of days of job transfer or restriction. You also classify whether the case is an injury or an illness and, if an illness, the type of illness.
How is MIOSHA Form 300 different from the federal OSHA Form 300?
MIOSHA’s recordkeeping system is closely aligned with federal OSHA’s, but Michigan operates its own state-plan program. Many of the concepts — such as keeping one log per establishment, recording cases within a set timeframe, and preparing an annual summary — are parallel, but employers in Michigan must follow MIOSHA’s specific rules and any Michigan-only requirements. This template is written to be adaptable while remaining focused on Michigan workplaces.
Does this MIOSHA Form 300 template count as legal or compliance advice?
No. This MIOSHA Form 300 – Log of Work-Related Injuries and Illnesses Template is only a drafting and organization tool. It does not replace official MIOSHA forms, regulations, or up-to-date guidance, and it does not determine whether a case is recordable or how serious injuries must be reported. For compliance questions, use current MIOSHA resources or seek advice from a qualified safety/HR professional or attorney.
How can AI Lawyer help with MIOSHA injury and illness logs?
AI Lawyer can help you organize information from internal incident reports — names, dates, locations, outcomes, and classifications — into a clear MIOSHA-style log using this template. You still decide which cases are recordable under MIOSHA, supply accurate data, and review the finished document. This template and any AI-generated content are for document organization only and are 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