b'YOUR TOOLKIT FOR BUILDING EXCELENCEAttention:This form contains information relating to the compliant. Again, DO OSHAs Form 300 (Rev.01/2004) employee health and must be used in a manner thatprotects the confidentiality of employees to the extent Year 20__ __Log of Work-Related Injuries and Illnesses possible while the information is being used for U.S. Department of Labor NOT forget that any safety occupational safety and health purposes. Occupational Safety and Health AdministrationYou must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, FormapprovedOMBno.1218-0176 violations observed by the days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed healthcare professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to Establishment name ___________________________________________use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this City ________________________________ State ___________________ CSHO, even if they are not form. If youre not sure whether a case is recordable, call your local OSHA office for help.Identify the person Jobtitle Describe the case eventoccurred Describeinjuryorillness,partsofbodyaffected, Classify the case Enter the number of Check the Injury column or noted on the complaint, CHECK ONLY ONE box for each case(A)(B)(C)(D) (E) (F) based on the most serious outcome for days the injured orCase Employeesname Dateofinjury Wherethe that case: ill worker was: choose one type of illness:no. (e.g.,Welder) oronset (e.g.,Loadingdocknorthend) andobject/substancethatdirectlyinjured on Days away J Remained at Work A om On job (M) willlikelyresultina Injury Skin disorder Respiratory condition Poisoning Hearing loss All other illnessesofillness ormadepersonill(e.g.,Seconddegreeburnsrightforearmfromacetylenetorch) O er record- frway transfer oroo abthle casesr bre tsrtarnicstfieornDeath from work work restriction (1) (2) (3) (4) (5) (6) citation and penalties. We (G) (H)(I) (J) (K) (L)_____ ________________________ ____________ __ ______________________ ___________________________________________________ ____ days ____ days____/_______________ ________________________ ____________ month/day ___________________ ___________________________________________________ ____ days ____ days will move on to the next ______/__________month/day_____ ________________________ ____________ __ ___________________ ___________________________________________________ ____ days ____ days step in the next issue.____/__________month/day_____ ________________________ ____________ __ ___________________ ___________________________________________________ ____ days ____ days____/__________month/day_____ ________________________ ____________ __ ___________________ ___________________________________________________ ____ days ____ days____/_______________ ________________________ ____________ month/day ___________________ ____________________________________________________ ____ days ____ days Remember, if you are an ______/__________month/day_____ ________________________ ____________ __ ___________________ ____________________________________________________ ____ days ____ days NFBA Member and you ____/__________month/day_____ ________________________ ____________ __ ___________________ ____________________________________________________ ____ days ____ days____/__________month/day_____ ________________________ ____________ __ ___________________ ____________________________________________________ ____ days ____ days have legal questions, you ____/__________month/day_____ ________________________ ____________ __ ___________________ ____________________________________________________ ____ days ____ days____/_______________ ________________________ ____________ month/day ___________________ ____________________________________________________ ____ days ____ days can use your NFBA Legal _____________/___month/day_____ ________________________ ____________ __ ___________________ ____________________________________________________ ____ days ____ days Services Plan to speak to ____/__________month/day_____ ________________________ ____________ __ ______________________ ____________________________________________________ ____ days ____ days____/___ _______Publicreporting thiscollection is month/day including review Page totalsGary Auman or one of the Injury Skin disorder Respiratory condition Poisoning Hearing loss All other illnessestheinstructions, burdenandfor gatherthe informationand estimatedandtoreviewaveragethe14collectionminutesofperinformation.response, Persons timenottorequired Be sure to transfer these totals to the Summary page (Form 300A) before you post it.dataofneeded,torespondtothe search any ofinformationunlessit , complete validOMBcontrolofnumberLabor,.OSHAIfyouhaveany are office. Page ____ of ____ (1) (2) (3) (4) (5) (6) other attorneys in his office. collection displaysacurrently commentsabouttheseRoomestimatesN-3644,or 200 otheraspectsAofvenue,thisdata Washington,contact:DC USDepartment thecompleted Officeof to StatisticalAnalysis, Constitution NWcollection, 20210.Donotsend forms thisContact NFBA for details OSHA Form 300 Log of work related injuries and illnesses or visit www.nfba.org. Laminated CoLumns LLCDistributor of Sturdi Walland Sturdi Wall Plus BracketsManufacturer of Quality Laminated Columns and Richland Perma-Columns3-Ply, 4-Ply, 2+6, 2+8100% Treated or Non TreatedSecatibe runtum earum sincilla velenimus auta nobit raecus di omnietSuperior Treatment#1SYP Lumber 30% Stronger than 6x6 solidThank you for another successful year!8252 Greenwich, Ohio 44837 Call Today for Nearest Distributor, Wholesale OnlyPhone: 419-895-0036FAX: 419-895-0062 We are now NEW!!!manufacturing the Manufacturing of an all Green Post! 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