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]

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]

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]

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]

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.

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]

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]