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]

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).

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]

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]

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

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]

On-site first aid only

Employer clinic / occupational health

Urgent care center

Hospital emergency department

Primary care provider

Specialist (orthopedist, ENT, etc.)

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

No

Did the injury or illness result in death?

• Yes – Date of death: [MM/DD/YYYY]

• No

Yes – Date of death: [MM/DD/YYYY]

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)

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]

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]

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

• Yes

• No

• Unsure

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]

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.)

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

• Yes

• Partially

• No

Partially

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

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

Yes – attached

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]

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

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.

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]

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)