OSHA Form 301 – Injury and Illness Incident Report Template

[Company / Employer Name]

[Establishment / Site Name]

[Street Address]

[City, State/Province, ZIP/Postal Code]

Phone: [Main Phone Number]

Email: [HR or Safety Email]

1. Case Identification

Case Number (from OSHA 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: [Department / Location]

Phone / Email: [Contact Details]

2. Employee Information

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

Home Address:

[Street Address]

[City, State/Province, ZIP/Postal 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 / 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, etc.):

[Example: “Warehouse – Loading Dock B,” “Production Line 2 – Conveyor Area,” “Office – Room 305,” “Construction Site – South Scaffold.”]

4. Work Activity at the Time of Incident

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

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

Employee’s Regular Work Task at That Time (if different from above):

[Describe or note “Same as above.”]

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:

[Suggested structure:]

• Describe what happened that led directly to the injury or illness (for example, “employee slipped on wet floor,” “hand caught between pallet and rack,” “inhaled chemical fumes while mixing product,” “struck by falling box from top shelf”).

• Identify the object, substance, or exposure that directly harmed the employee (for example, “concrete floor,” “metal edge,” “moving forklift,” “cleaning chemical,” “loud noise from press”).

• Indicate the sequence of events: what the employee was doing, what went wrong, and how the body was affected.

Describe what happened that led directly to the injury or illness (for example, “employee slipped on wet floor,” “hand caught between pallet and rack,” “inhaled chemical fumes while mixing product,” “struck by falling box from top shelf”).

Identify the object, substance, or exposure that directly harmed the employee (for example, “concrete floor,” “metal edge,” “moving forklift,” “cleaning chemical,” “loud noise from press”).

Indicate the sequence of events: what the employee was doing, what went wrong, and how the body was affected.

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 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 injury – [Description]

• Repetitive strain / overuse – [Description]

• Respiratory condition – [Description]

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

• Poisoning or toxic exposure – [Description]

• Hearing loss / acoustic trauma – [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 injury – [Description]

Repetitive strain / overuse – [Description]

Respiratory condition – [Description]

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

Poisoning or toxic exposure – [Description]

Hearing loss / acoustic trauma – [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 organs / 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 organs / 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 room

• Primary care physician

• Specialist (orthopedist, ENT, etc.)

• Other: [Describe]

On-site first aid only

Employer clinic / occupational health

Urgent care center

Hospital emergency room

Primary care physician

Specialist (orthopedist, ENT, etc.)

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

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

Facility Address (optional): [City, State/Province]

Was the employee hospitalized overnight as an in-patient?

• Yes

• No

Yes

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 the incident result in 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 OSHA-recordable)

Death

Days away from work

Job transfer or restricted work

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

If days away from work occurred:

Number of Calendar Days Away from Work (to date or final): [Number of days]

If job transfer or restricted work occurred:

Number of Calendar Days of Restricted Work or Job Transfer (to date or final): [Number of days]

Briefly describe any work restrictions or modified duties (for example, “no lifting over 10 lbs,” “seated work only,” “no overhead reaching,” “shortened shifts”):

[Description]

9. Personal Protective Equipment and Safety Controls

Was personal protective equipment (PPE) required for the 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, safety devices, or controls 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 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

• Employee re-instructed on procedure

• PPE updated or reinforced

• Other: [Describe]

Hazard removed or area cleaned

Equipment taken out of service

Temporary barriers, cones, or warning signs placed

Employee re-instructed on procedure

PPE updated or reinforced

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

[Free-text description]

12. Privacy Case (If Applicable)

Some sensitive cases may qualify as “privacy cases” under OSHA recordkeeping rules (for example, certain injuries to intimate body parts, mental illnesses, or other sensitive conditions).

Is this case being treated as an OSHA privacy case?

• No

• Yes – employee’s name will be replaced with “Privacy Case” on the OSHA 300 log, and a separate confidential list will link the case number to the employee’s identity.

Yes – employee’s name will be replaced with “Privacy Case” on the OSHA 300 log, 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:

• OSHA 300 log entry for this case (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 incident

• Training records for task/equipment involved

• Other supporting documents: [Describe]

OSHA 300 log entry for this case (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 incident

Training records for task/equipment involved

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)