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MIOSHA Form 300A – Summary of Work-Related Injuries and Illnesses Template
Summarize your annual Michigan work-related injury and illness data in a clear, MIOSHA-style format for posting and recordkeeping.
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MIOSHA Form 300A – Summary of Work-Related Injuries and Illnesses Template
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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
Total number of:
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]
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MIOSHA Form 300A – Summary 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 300A SUMMARY TEMPLATE FAQ
What is MIOSHA Form 300A – Summary of Work-Related Injuries and Illnesses?
MIOSHA Form 300A is the annual summary of OSHA/MIOSHA-recordable work-related injuries and illnesses for a specific calendar year at a Michigan establishment. It uses totals from your MIOSHA Form 300 log and shows the number of cases, days away/restricted, and types of injuries and illnesses, along with basic establishment information and a certification by a company executive.
Who must complete and post a MIOSHA 300A-style summary?
Most Michigan employers that are required to keep OSHA/MIOSHA injury and illness records must prepare a yearly summary for each covered establishment and post it where employees can see it for a defined period, even if there were zero recordable cases. Some small or low-hazard employers may be partially exempt, so it’s important to confirm your status under current MIOSHA rules or with a qualified safety/HR professional.
What information goes into a MIOSHA Form 300A summary?
A MIOSHA 300A summary typically includes: the calendar year; establishment name and address; industry or NAICS code; average number of employees; total hours worked; total number of cases by classification (deaths, cases with days away, cases with job transfer/restriction, other recordable); total days away and restricted/transfer days; and total counts by injury/illness type. A company executive then reviews and signs the summary.
Does the MIOSHA 300A summary replace the MIOSHA Form 300 log?
No. The 300A summary is a high-level snapshot for posting and review. It does not replace the detailed MIOSHA Form 300 log or your incident reports (such as Form 301 or internal equivalents). You must still maintain the log and supporting records for the required retention period.
Is this MIOSHA Form 300A template legal or compliance advice? Do I still need a safety or legal professional?
This MIOSHA Form 300A – Summary template is only a drafting aid to help you organize information from your own logs. It does not determine which cases are recordable, set posting or reporting deadlines, or guarantee compliance. For questions about MIOSHA recordkeeping, reporting severe injuries, or your specific obligations, you should consult current MIOSHA guidance or speak with a qualified safety/HR professional or attorney.
How can AI Lawyer help with MIOSHA 300A summaries?
AI Lawyer can help you take totals from your MIOSHA Form 300 log and format them into a clear, consistent summary using this template. You still provide the actual numbers, verify their accuracy, and make final decisions about recordability and compliance. Any AI-generated content is for document organization and drafting support only, not legal or safety advice.
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