OSHA Form 300A: Work-Related Injuries & Illnesses Template

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

[Company / Establishment Name]

[Street Address]

[City, State, ZIP Code]

[Industry Description or NAICS Code]

1. Year and Establishment Information

Calendar Year Covered by This Summary: [Year]

Establishment Name: [Name of Individual Establishment or Site]

Address: [Street Address, City, State, ZIP Code]

Industry / Business Description: [Short description, e.g., “Warehouse and distribution,” “Metal fabrication,” “Office – professional services,” etc.]

NAICS Code (if known): [NAICS Code]

Average Number of Employees During the Year: [Number]

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

2. Summary of OSHA-Recordable Cases

Use totals from your OSHA 300 log for the same calendar year. Enter “0” for any category 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 OSHA-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 OSHA-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 Information for Posting

This section is typically visible when the summary is posted where employees can see it.

Company / Establishment Name: [Name]

City: [City]

State: [State]

Contact Person for More Information About This Summary:

Name: [Full Name]

Title: [Title – e.g., Safety Manager, HR Manager]

Phone: [Phone Number]

Email (optional): [Email Address]

4. Certification by Company Executive

OSHA requires that a company executive review the injury and illness records and certify that the OSHA 300A summary is correct and complete, based on the OSHA 300 log.

I certify that I have examined this OSHA-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 (only if the company is a sole proprietorship or partnership)

• Officer of the corporation

• 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 (only if the company is a sole proprietorship or partnership)

Officer of the corporation

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

This section helps you organize how and where the summary is posted for employees.

Date Summary Prepared: [MM/DD/YYYY]

Posting Period (typically required by OSHA rules):

From: [MM/DD/YYYY]

To: [MM/DD/YYYY]

Location(s) Where This Summary Will Be Posted (break room, main bulletin board, time clock area, etc.):

[Description of posting locations]

Name or Role of Person Responsible for Posting: [Name/Title]

6. Recordkeeping and Additional Notes

Recordkeeping Reminder:

• Keep this OSHA-style summary, your OSHA 300 log, and any OSHA 301 or equivalent incident reports for at least five years following the end of the calendar year to which they relate (or longer if required by law or company policy).

• During the retention period, you may need to update your OSHA 300 log if case outcomes change (for example, additional days away from work).

Keep this OSHA-style summary, your OSHA 300 log, and any OSHA 301 or equivalent incident reports for at least five years following the end of the calendar year to which they relate (or longer if required by law or company policy).

During the retention period, you may need to update your OSHA 300 log if case outcomes change (for example, additional days away from work).

Internal Notes (optional):

[Use this section for internal references, such as “Totals checked against 300 log on 01/20/2026,” “Updated after reclassification of Case #7,” or references to internal safety reviews.]

7. Attachments Checklist (Internal Use)

You may keep the following documents together with this OSHA 300A-style summary in your injury and illness recordkeeping file:

• OSHA 300 log for this calendar year

• OSHA 301 forms or equivalent incident reports for each recordable case

• Internal accident / incident investigation reports

• Workers’ compensation or insurance claim summaries

• Safety committee or management review notes related to this year’s cases

• Any correspondence with OSHA or regulatory agencies about recorded cases

• Other supporting documents: [Describe]

OSHA 300 log for this calendar year

OSHA 301 forms or equivalent incident reports for each recordable case

Internal accident / incident investigation reports

Workers’ compensation or insurance claim summaries

Safety committee or management review notes related to this year’s cases

Any correspondence with OSHA or regulatory agencies about recorded cases

Other supporting documents: [Describe]