MIOSHA Form 300A Template: Injury & Illness Summary Form

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

[Company / Establishment Name]

[Street Address]

[City, State (MI), 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: [MI]

ZIP Code: [ZIP Code]

Industry / Business Description: [Short description, e.g., “Manufacturing – automotive parts,” “Warehouse and distribution,” “Construction,” “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 (this establishment only): [Total hours]

2. Summary of MIOSHA-Recordable Cases

Use totals from your MIOSHA Form 300 log for the same calendar year. Enter “0” 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 MIOSHA-recordable): [Number]

2.2 Number of Days

• 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 MIOSHA injury and illness records and certify that this summary is true and complete, based on the MIOSHA Form 300 log for this establishment.

I certify that I have examined this MIOSHA-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 to current MIOSHA/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 MIOSHA 300A-style summary, your MIOSHA Form 300 log, and incident reports (Form 301 or equivalents) for at least the minimum number of years required by MIOSHA and your internal policies.

• During the retention period, you may need to update your MIOSHA Form 300 log if the 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 are available for inspections, audits, or internal safety reviews.

Internal Notes (optional):

[Use this area for internal remarks, such as “Totals checked against MIOSHA 300 log on [date],” “Summary revised after reclassification of Case #[X],” or references to safety committee reviews.]

7. Attachments Checklist (Internal Use)

You may keep the following documents with this MIOSHA 300A-style summary as part of your injury and illness recordkeeping file:

• MIOSHA Form 300 log for this calendar year

• MIOSHA 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 MIOSHA or other authorities about recorded cases

• Other supporting documents: [Describe]