OSHA Form 300 Template: Work-Related Injuries & Illness Log

OSHA Form 300 – Log of Work-Related Injuries and Illnesses Template

[Company / Establishment Name]

[Street Address]

[City, State, ZIP Code]

[Industry Description or NAICS Code]

Year Covered by This Log: [Calendar Year]

1. Establishment Information

Establishment Name: [Name of Establishment / Site]

Address of Establishment: [Street, City, State, ZIP]

City: [City]

State: [State]

ZIP: [ZIP Code]

Industry / Business Description: [Short description, e.g., “warehouse and distribution,” “office – professional services,” “manufacturing,” etc.]

NAICS Code (if known): [NAICS Code]

Average Number of Employees During the Year: [Number]

Total Hours Worked by All Employees This Year: [Total Hours]

2. Instructions for Using This Log

• Use this log to record each OSHA-recordable work-related injury or illness that occurs during the calendar year indicated above.

• Use one “Log Entry” block (Section 3) for each case. Assign case numbers in order (e.g., 1, 2, 3…).

• Do not record first-aid-only cases that are not OSHA-recordable.

• Update days away from work and restricted/transfer days if they change after the initial entry, up to OSHA’s maximum count rules.

• Use separate incident reports (e.g., OSHA 301 or equivalent) to document detailed circumstances for each case.

Use this log to record each OSHA-recordable work-related injury or illness that occurs during the calendar year indicated above.

Use one “Log Entry” block (Section 3) for each case. Assign case numbers in order (e.g., 1, 2, 3…).

Do not record first-aid-only cases that are not OSHA-recordable.

Update days away from work and restricted/transfer days if they change after the initial entry, up to OSHA’s maximum count rules.

Use separate incident reports (e.g., OSHA 301 or equivalent) to document detailed circumstances for each case.

3. OSHA 300 Log Entry Template (Repeat for Each Case)

Log Entry – Case [Case Number]

Basic Case Information

Case Number: [Sequential Number for the Year]

Employee Name: [First, Middle, Last]

Employee Job Title: [Job Title at Time of Incident]

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

Where the Event Occurred (work area or location):

[Example: “Warehouse – Loading Dock B,” “Office – Room 210,” “Construction site – south scaffold,” “Parking lot,” etc.]

Describe Injury or Illness, Parts of Body Affected, and Object/Substance That Directly Injured or Made Person Ill:

[Short narrative, examples: “Strain – lower back while lifting box,” “Laceration – left hand from box cutter,” “Slip and fall on wet floor – bruised right hip and elbow,” “Inhalation of chemical fumes – respiratory symptoms.”]

Case Classification (Check One)

This case involved:

• Death

• Days away from work

• Job transfer or restriction

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

Death

Days away from work

Job transfer or restriction

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

Days Away from Work and Job Transfer/Restriction

Number of Days Away from Work: [Number of calendar days]

Number of Days of Job Transfer or Restricted Work: [Number of calendar days]

Type of Case – Injury or Illness Category (Check One)

Check the category that best describes the case:

• Injury

• Skin disorder

• Respiratory condition

• Poisoning

• Hearing loss

• Other illness

Injury

Skin disorder

Respiratory condition

Poisoning

Hearing loss

Other illness

Privacy Case (If Applicable)

Certain sensitive cases may be treated as “privacy cases” under OSHA recordkeeping rules (for example, some injuries to intimate body parts, mental illnesses, or other sensitive conditions).

Is this a privacy case as defined by OSHA?

• No

• Yes – record “Privacy Case” instead of employee’s name on the log and keep a separate confidential list linking the case number to the employee’s identity.

No

Yes – record “Privacy Case” instead of employee’s name on the log and keep a separate confidential list linking the case number to the employee’s identity.

Additional Notes (Optional)

[Use this space for brief internal notes such as “updated days away on 06/01,” “case converted from restricted work to days away,” or references to associated incident report numbers.]

4. Supplemental Privacy Case List (Optional Internal Use)

If you designate any cases as privacy cases, maintain this list separately and securely.

Privacy Case List Year: [Calendar Year]

For each privacy case, record:

• Case Number: [From the OSHA 300 log]

• Employee Identifier: [Full name or internal ID – kept confidential]

• Notes (optional, e.g., “Case relates to Section 1904 privacy criteria”).

Case Number: [From the OSHA 300 log]

Employee Identifier: [Full name or internal ID – kept confidential]

Notes (optional, e.g., “Case relates to Section 1904 privacy criteria”).

5. Annual Review and OSHA Form 300A Preparation

At the end of the calendar year:

1. Review each log entry for accuracy (case classification, days away, days restricted/transfer, and type of case).

2. Summarize totals for:

   • Number of deaths

   • Number of cases with days away from work

   • Number of cases with job transfer or restriction

   • Number of other recordable cases

   • Total days away from work

   • Total days of job transfer or restriction

   • Number of cases in each injury/illness category (injury, skin disorder, etc.)

3. Use these totals to complete the OSHA Form 300A – Summary of Work-Related Injuries and Illnesses.

4. Have a company executive certify the accuracy of the log and summary, as OSHA requires.

Review each log entry for accuracy (case classification, days away, days restricted/transfer, and type of case).

Summarize totals for:

• Number of deaths

• Number of cases with days away from work

• Number of cases with job transfer or restriction

• Number of other recordable cases

• Total days away from work

• Total days of job transfer or restriction

• Number of cases in each injury/illness category (injury, skin disorder, etc.)

Number of deaths

Number of cases with days away from work

Number of cases with job transfer or restriction

Number of other recordable cases

Total days away from work

Total days of job transfer or restriction

Number of cases in each injury/illness category (injury, skin disorder, etc.)

Use these totals to complete the OSHA Form 300A – Summary of Work-Related Injuries and Illnesses.

Have a company executive certify the accuracy of the log and summary, as OSHA requires.

6. Certification of the Log (Internal Use)

I certify that I have examined this OSHA-style log of work-related injuries and illnesses and that, to the best of my knowledge, it is a true and complete record of OSHA-recordable incidents for the year indicated.

Name of Certifying Official: [Full Name]

Title: [Title – e.g., Company Executive, Owner, Officer, Highest Ranking Official at This Establishment]

Signature: _______________________________

Date: [MM/DD/YYYY]

7. Attachments and Supporting Documents Checklist

For each log entry, you may keep related documents with your OSHA recordkeeping file (paper or electronic). Check any that apply:

• OSHA Form 301 or equivalent incident report for each case

• Internal incident or accident investigation reports

• Medical reports or work-status notes related to the case

• Employee statements and witness statements

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

• Correspondence with workers’ compensation carrier or insurer

• Any corrective action or safety review documentation

OSHA Form 301 or equivalent incident report for each case

Internal incident or accident investigation reports

Medical reports or work-status notes related to the case

Employee statements and witness statements

Photos or sketches of the incident scene (if kept)

Correspondence with workers’ compensation carrier or insurer

Any corrective action or safety review documentation