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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 wolk- aolated injury or illness Nat involves loss of oonsdousness, resideledwDik aclivily or job Iransref, days away I=work, or medical healmenl <br />beyond first aid. You musk also record ci0nificaN vanik- rdfaled injuries and illnesses that are diagnosed by a physldan or licensed heaflh care professional. Yw must also record work - <br />relafedfnjurtes and illnesses ilia[ meet any of the specific recording criteria listed in 29 CFR 1909.6 through 19(14.12. Feel Iree (a use Iwo lines for a single case if you need to You must <br />canplele an tnlury and illness incidenl report (OSHA Forth 301) or equivalent form rot each injury or Mnoes recorded oa this form. If you're nol sure whether a case is recordable, calf your <br />local OSHA office for help. <br />Identify the person <br />(A) (B) (GJ {D) <br />Case Employee's Job T €Ile (e.g.. Date of <br />No. Name Welder InJury or <br />onset of <br />Illness <br />(mo.lday) <br />Establishment name <br />Raleigh <br />City <br />Form approved OMB no, 1218 -0176 <br />Waste Industries, LLC <br />Stele NC <br />... <br />Describe the case Glassify.lhe case <br />(E) (F) CHECK ONLY ONE box For each case based on Enter the number of Check the "Injury" column or choose one type <br />Where the event occurred (e.g. Describe injury or Illness, parts of body affected, and the most serious outcome for that case: (days the Injured or ill of illness: <br />Loading dock north end) object/substance [hat directly injured or made person <br />IF (e.g. Second degree burns on right forearm from <br />acetylene torch) - - - - - - - - <br />Dealh : Days away I Reifmine.d alwork;. Away On job <br />'. from Wdrk -i. from transfer or <br />work restriction <br />(days) (days) <br />IJob transfer Otherrecord- c <br />or restriction able cases _ <br />Bennelh <br />C <br />Attention: This form canlalns information <br />Transfer station <br />relating 10 employee health and must be used In <br />a manner that protects the confidentiality of <br />Year ��� <br />employees 10 the extent possible while the <br />U.B. Department of Labor <br />Information is being used for occupational safely <br />left shoulder strain from lipping Carl <br />and health purposes. <br />9112 <br />Occupational Safely and Health Administration <br />You must record information about every wolk- aolated injury or illness Nat involves loss of oonsdousness, resideledwDik aclivily or job Iransref, days away I=work, or medical healmenl <br />beyond first aid. You musk also record ci0nificaN vanik- rdfaled injuries and illnesses that are diagnosed by a physldan or licensed heaflh care professional. Yw must also record work - <br />relafedfnjurtes and illnesses ilia[ meet any of the specific recording criteria listed in 29 CFR 1909.6 through 19(14.12. Feel Iree (a use Iwo lines for a single case if you need to You must <br />canplele an tnlury and illness incidenl report (OSHA Forth 301) or equivalent form rot each injury or Mnoes recorded oa this form. If you're nol sure whether a case is recordable, calf your <br />local OSHA office for help. <br />Identify the person <br />(A) (B) (GJ {D) <br />Case Employee's Job T €Ile (e.g.. Date of <br />No. Name Welder InJury or <br />onset of <br />Illness <br />(mo.lday) <br />Establishment name <br />Raleigh <br />City <br />Form approved OMB no, 1218 -0176 <br />Waste Industries, LLC <br />Stele NC <br />... <br />Describe the case Glassify.lhe case <br />(E) (F) CHECK ONLY ONE box For each case based on Enter the number of Check the "Injury" column or choose one type <br />Where the event occurred (e.g. Describe injury or Illness, parts of body affected, and the most serious outcome for that case: (days the Injured or ill of illness: <br />Loading dock north end) object/substance [hat directly injured or made person <br />IF (e.g. Second degree burns on right forearm from <br />acetylene torch) - - - - - - - - <br />Dealh : Days away I Reifmine.d alwork;. Away On job <br />'. from Wdrk -i. from transfer or <br />work restriction <br />(days) (days) <br />IJob transfer Otherrecord- c <br />or restriction able cases _ <br />Bennelh <br />C <br />2121 <br />Transfer station <br />RL ringfindex linger caught between armlbody equip <br />a <br />616 <br />left arm and shoulder <br />left shoulder strain from lipping Carl <br />H <br />9112 <br />Jones Ferry rd Chapel Hill NC <br />missed step on truck confusion to rl knee,left wd <br />Jeff <br />C <br />Y <br />9130 <br />right ElbowfForearm <br />Strain right forearm from picking up can <br />, Jose <br />Driver- Roll Off <br />9125 <br />Landfill location <br />pushing on a very dgid tailgate hurt lower back <br />Public mpwling burden for this collection of information is estimated to average 14 minules per reepomu, <br />irrdudimg limo to ruview the inskudion, search and gather the dala needed, and complete and review <br />ilia collection of informalian. Perconn are not required [otespond to the cdiecfion or infwmalion unless it <br />displays a currently valid OMB corlhof number. If you have any cernmenls abeul these eslfmates or any <br />aspects al this data collection, conlxl: US Deparfinenl of Labor, OSFIA Office of Slatislics, Room N -3644, <br />200 Constlu1W Ave, NW, IN"ringlon, DC 20210. Do not send the completed forms to this office. <br />Be sure to transfer these totals to the <br />Page 1 of 1 <br />X <br />X <br />X <br />X <br />X <br />1 4 0 <br />a (Form 300A) before you post it. <br />(L) <br />o <br />C <br />a <br />r N <br />a <br />O <br />H <br />N C <br />J <br />V <br />U <br />r>• <br />c — <br />ro W <br />C <br />Y <br />G <br />L <br />S <br />C <br />M <br />N <br />za O <br />n <br />n <br />a- <br />x Q <br />o <br />a <br />r N <br />o <br />Q <br />H <br />tl <br />V <br />U <br />o <br />a <br />c — <br />ro W <br />C <br />Y <br />O <br />L <br />S <br />n <br />S <br />m <br />rC <br />(1) (2) <br />(3) <br />(4) <br />(5) (B) <br />N <br />