MIOSHA Form 301 – Injury and Illness Incident Report Template

[Company / Employer Name]

[Establishment / Site Name]

[Street Address]

[City, State (MI), ZIP Code]

Phone: [Main Phone Number]

Email: [HR or Safety Email]

1. Case Identification

Case Number (matching MIOSHA Form 300 log, if applicable): [Case Number]

Date of Report: [MM/DD/YYYY]

Person Completing This Report: [Full Name]

Job Title: [Title – e.g., Supervisor, Safety Officer, HR]

Department / Work Area: [Department / Area]

Phone: [Direct Phone]

Email: [Work Email]

2. Employee Information

Full Legal Name of Injured / Ill Employee: [First, Middle, Last]

Home Address:

[Street Address]

[City, State, ZIP Code]

Date of Birth: [MM/DD/YYYY]

Gender: [Gender]

Date Hired (approximate if needed): [MM/DD/YYYY or MM/YYYY]

Employee ID / Payroll Number (if used internally): [ID Number]

Job Title at Time of Incident: [Job Title]

Department / Regular Work Area: [Department / Area]

3. Incident Date, Time, and Location

Date of Injury or Onset of Illness: [MM/DD/YYYY]

Time of Event (approximate if necessary): [HH:MM a.m./p.m.]

Time Employee Began Work on Day of Incident: [HH:MM a.m./p.m.]

Number of Hours Employee Had Worked Before Event Occurred: [Number of hours, e.g., “2 hours”]

Exact Location Where the Event Occurred (building, floor, room, work area, machine, vehicle, job site, etc.):

[Example: “Plant 1 – Assembly Line A,” “Warehouse – Loading Dock 2,” “Office – Room 305,” “Job site – roof area,” “Parking lot – south side.”]

4. Work Activity at the Time of Incident

Describe the activity the employee was performing just before the incident. Include the specific task, tools, equipment, materials, or substances being used.

[Example: “Lifting 40-lb boxes from pallet to conveyor,” “Using a power drill to install overhead brackets,” “Walking through warehouse aisle carrying pick list,” “Cleaning floor with mop and bucket,” etc.]

Was this the employee’s usual work activity?

• Yes

• No – describe regular duties: [Description]

5. How the Injury or Illness Occurred

Provide a brief, factual description of how the injury or illness occurred. Focus on what happened, not who is at fault.

Incident Narrative (What Happened):

[Suggested structure:]

• What the employee was doing at the time.

• What went wrong (slip, trip, fall, struck by/against, caught in/between, overexertion, repetitive motion, exposure, etc.).

• The object, substance, or exposure that directly caused the injury or illness (floor, step, machine part, tool, chemical, noise, heat, etc.).

• How the body was affected (part(s) of body, type of impact or exposure).

Free-Text Description:

[Incident narrative]

6. Nature of Injury or Illness

Describe the injury or illness and part(s) of the body affected.

Type of Injury or Illness (check all that apply and briefly describe):

• Bruise / contusion – [Description]

• Cut / laceration – [Description]

• Abrasion / scrape – [Description]

• Sprain / strain / soft tissue – [Description]

• Fracture / suspected fracture – [Description]

• Dislocation – [Description]

• Burn (thermal / chemical / electrical) – [Description]

• Crush or pinch injury – [Description]

• Puncture wound – [Description]

• Repetitive strain / overuse – [Description]

• Respiratory condition – [Description]

• Skin disorder (rash, irritation, allergic reaction) – [Description]

• Poisoning or toxic exposure – [Description]

• Hearing loss / noise-related condition – [Description]

• Other illness: [Describe]

Body Part(s) Affected (check or list all that apply):

• Head / scalp

• Face / eye / nose / mouth / jaw

• Neck / cervical spine

• Shoulder / arm / elbow

• Wrist / hand / fingers

• Chest / ribs

• Upper / mid-back

• Lower back / lumbar area

• Hip / pelvis

• Thigh / hamstring / quadriceps

• Knee

• Lower leg / shin / calf

• Ankle

• Foot / toes

• Multiple body parts

• Internal organ(s) / system (specify): [Description]

• Other: [Describe]

Employee’s Reported Symptoms (brief):

[Example: “Sharp pain in lower back when bending,” “Swelling and tenderness in right ankle,” “Tingling in fingers,” “Shortness of breath,” “Headache and ringing in ears.”]

7. Medical Treatment and Outcome

Did the employee receive medical treatment beyond basic first aid?

• No – first aid only

• Yes – medical treatment beyond first aid

Initial Medical Treatment Location (check all that apply):

• On-site first aid only

• Employer clinic / occupational health

• Urgent care center

• Hospital emergency department

• Primary care provider

• Specialist (orthopedist, ENT, etc.)

• Other: [Describe]

Name of Treating Healthcare Professional (if known): [Name]

Medical Facility Name: [Clinic / Hospital / Practice Name]

Facility City / State: [City, State]

Was the employee hospitalized overnight as an in-patient?

• Yes

• No

Did the injury or illness result in death?

• Yes – Date of death: [MM/DD/YYYY]

• No

8. Work Restrictions and Days Away from Work

Did this case involve any of the following? (check all that apply):

• Death

• Days away from work

• Job transfer or restricted work

• Other recordable case (no days away or restrictions, but MIOSHA-recordable)

Number of calendar days away from work (to date or final): [Number of days]

Number of calendar days of restricted work or job transfer (to date or final): [Number of days]

Describe any medical work restrictions or modified duties (for example, “no lifting over 10 lbs,” “no climbing ladders,” “seated work only,” “shortened shifts,” etc.):

[Description]

9. Workplace Conditions, PPE, and Safety Controls

Were any of the following conditions present at the time of the incident? (check and describe if applicable):

• Wet or slippery surface (water, oil, cleaning solution, etc.) – [Describe]

• Uneven floor, step, or obstruction – [Describe]

• Cluttered or blocked walkway – [Describe]

• Poor lighting or visibility – [Describe]

• Noise, vibration, or heat – [Describe]

• Moving machinery or equipment – [Describe]

• Vehicle or mobile equipment (forklift, truck, pallet jack, etc.) – [Describe]

• Defective or damaged tool/equipment – [Describe]

• Chemical, dust, fumes, or biological exposure – [Describe]

• Inadequate guarding or fall protection – [Describe]

• Weather-related factor (if outdoors) – [Describe]

• Other: [Describe]

Was personal protective equipment (PPE) required for this task?

• Yes

• No

• Unsure

If Yes, what PPE was required? (check all that apply):

• Safety glasses / goggles

• Face shield

• Hard hat

• Hearing protection

• Gloves (type): [Describe]

• Safety shoes / boots

• High-visibility clothing

• Respirator / mask

• Fall protection (harness, lanyard, etc.)

• Other: [Describe]

Was the employee using required PPE at the time of the incident?

• Yes

• Partially

• No

If partially or no, briefly explain:

[Description]

Were any machine guards, interlocks, or other safety devices bypassed, disabled, or not functioning?

• No

• Yes – describe: [Description]

• Unknown

10. Witnesses and Additional Information

Witnesses to the Incident or Immediate Aftermath (if any):

Witness 1:

Name: [Name]

Job Title / Role: [Role]

Department: [Department]

Phone / Email: [Contact Details]

Witness 2:

Name: [Name]

Job Title / Role: [Role]

Department: [Department]

Phone / Email: [Contact Details]

[Add additional witnesses as needed.]

Have written witness statements been collected?

• Yes – attached

• No

• Planned / requested

11. Corrective Actions and Prevention (Internal Use)

Based on information available at the time of this report, note any immediate or planned corrective actions to help prevent similar incidents:

Immediate Actions Taken (check and describe):

• Hazard removed or area cleaned

• Equipment taken out of service

• Temporary barriers, cones, or warning signs placed

• Work stopped in affected area

• Employee re-instructed on safe procedure

• PPE updated or reinforced

• Other: [Describe]

Planned Follow-Up Actions (investigation, engineering changes, training, policy updates, etc.):

[Free-text description]

12. Privacy Concern Cases

Some sensitive cases may qualify as “privacy concern cases” under OSHA/MIOSHA recordkeeping rules.

Is this case being treated as a privacy concern case?

• No

• Yes – the MIOSHA Form 300 log will list “Privacy Case” instead of the employee’s name, and a separate confidential list will link the case number to the employee’s identity.

13. Attachments Checklist

Check all documents attached or maintained with this incident report:

• MIOSHA Form 300 log entry (or notation of case number)

• Internal accident / incident investigation report

• Medical reports or work-status notes (if provided)

• Witness statements

• Photos or sketches of the incident scene (if kept)

• Maintenance or inspection records related to the equipment/area

• Training records related to the task or equipment involved

• Workers’ compensation claim forms or summaries

• Other supporting documents: [Describe]

14. Review and Signatures

Person Completing This Report

Name (print): _______________________________

Job Title: _________________________________

Signature: __________________________________

Date: [MM/DD/YYYY]

Supervisor / Manager (If Different)

Safety / HR / Risk Management (Optional)