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OSHA's Form 300 (Rev. 0112004) <br />Log of Work - Related Injuries and Illnesses <br />You must record information about every work - related injury or illness that involvesiess of consciousness, restricted wmk activily of job Imndei, days away from wok, or medical healment <br />beyond fast aid. You must alsu record signiricanl work- retaled Injuries and illnesses that are diagnosed by a physician a licensed health care professional. You must 960 record work - <br />relatediry'urtes and illnesses that meet any of the speoifciecording edleria listed In 29 CFR 1904.8 through 1984.12. Feel free to use Iwo lines for a single case if youneed lo. You must <br />cemoele an injury and illness incident repel (OSHA Form 301) or equivalent form far each injury a illness recorded on this form. If you're not sutewhelher a case is recordable, call your <br />local OSHA office for help. <br />(A) (B) (C) (D) <br />Case Employee's Job Title (e.g., Oate of <br />No. Name Welder Injury or <br />onsetaf <br />Illness <br />(mo./day. <br />the event occurred (e.g. <br />I dock north end) <br />Ationtiow This farm contains Informallon <br />relating to employee health and must be used in <br />a manner that protects the conffdenitakly of <br />emptoyees to the extent possible while the <br />information Is being used for occupational safely <br />and health purposes. <br />Establishment name <br />Raleigh <br />City <br />Year 9r„9 �� <br />U.S. Department of Labor <br />Occupational Safely and Health Administration <br />Farm approved OMB no, 1216 -0176 <br />Waste Industries, LLC <br />State NC <br />ecasa Glassifylhacasa w <br />(F} CHECK ONLY ONE box for each case based on Enter the number of Check the "Injury" column or choose one typeI' <br />Describe Injury or illness, parts of body affected, and the most serious outcome for that case: (days the Injured or III I of Illness: 1 <br />ob)ectlsubstance that directly injured or made person a <br />ill (e.g. Second degree burns an right forearm from - <br />acetylene! torch) -. <br />(M) <br />Death ;Daysaway< I Remainedatwprk Away Onjob <br />`;from Work from transferor <br />work restriction <br />(days) (days) <br />IJob transfer ]Other record- C <br />or restriction lable cases <br />� Iu <br />° <br />y U y <br />� "c <br />m <br />m <br />i a o' — <br />n <br />If :2 (G) (H) (1) (J) (K} (L) (1) (2) I (3) ! (4) 1 (51 1 (6) <br />^,Sr„­€119 strain/ Legs &shoulder strain! Legs& shoulder from car accident X <br />= 9e6.,111r1 715 604 Creekslone Ln Neck injury from vehicle accident X <br />7117 Queensbury circle Sprained knee from slipping in grass X <br />mg Longview rd Chapel Hill Dehydration heal related X <br />- Roll Off 7127 on route right arm was infected due to and bites X <br />- Front End 11119 Foerhead EE hit head on top of truck from bump in rd X <br />- Roll Off 11126 WCA dump facility Raleinh. NC sprain to lower back from pushing door shut on irk X <br />0 2 2 3 <br />Pubile repm0ng burden for this collodion of Intormatton Is estimated to average 14 minutes per response, <br />including lime to review theinslruclien, search and gather His data needed, and cornplels and review <br />the collection of information. Poisons are not required to respond to the collection of infomatlon unless it <br />displays a cunenlly valid OMB canbol number. II you have any comments about these estimates many <br />aspeclsof this data collection, contact: US Department of Labm, OSHA Office of Stallstics, Room N -3644, <br />260 Conslitutim Ave, NW, Washington, DC 2020, Do not send the completed forms to thisofrice. <br />Be sure to transfer these lulals to the Summary page (Form 300A) before you post It. <br />Page t of 1 <br />15 <br />2 <br />0 <br />O <br />9 <br />p <br />G - <br />U <br />U <br />n- <br />m <br />c <br />o <br />u v <br />uxj <br />m <br />z o <br />a <br />o: <br />(1) (2) <br />(3) <br />(4) <br />(5) (6) <br />0 <br />