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<br /> Attention:This form contains information relating to
<br /> OSHA's Form 300 (Re,oymcw employee health and must be used in a manner that Co
<br /> protects the confidentiality of employees to the extent Year 2014 0
<br /> Log of Work-Related Injuries and Illnesses
<br /> possible while the information is being used for us,Department of Labor
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<br /> occupational safety and health purposes. u�upatfana,54tatyandM-Hhadndn1str26on 00
<br /> You must record Information about every work related death and about every work-related injury or illness that involves loss of consciousness,restricted work activity orjob tans/er, Perm approved OMB no.1218-0176 cJn
<br /> days away from work,or medical treatment beyond first aid.You must also record c.n
<br /> signfilcanl work-related Injuries and illnesses that are diagnosed by a physician or licensed health W
<br /> care professional You must also record work-related injuries and Illnesses they meet any of the spaciffc recording criteria fisted in 29 CFR Part 1964.8 through 1904.12.Feel free to r araASSnmenrnama;�aeanelli CgRS'tYllefioTA s6llfh
<br /> use two lines fore single case if you Head to.You must complete en Injury and Illness incident Report(OSHA Form 301)or equivalent Sam for each injury or illness recorded on this m
<br /> form.ffyou're not sure whether a case is recordable,call your local OSHA office for help. c,, Apex sa„e NC m case 00
<br /> Identify the person Classify the case U
<br /> (A) (g) (C) ' (D) •- - (E) (� F'nter� , Gft!�r •��.ri Co
<br /> Case Employees Hume days the InJuroat a ,, Y
<br /> job tit? Date of injury Where the event occurred Desrn'be injury or itlnessr puts of body aftec4d, ill worker war. "'"b'r'r"1" 'i' " '•;h_k 00
<br /> no. (e.g,Welder) or onset (e..,I.owLi� dick nMV4 e ,
<br /> g y rid) andobject/snbsiance that directly injured W
<br /> of illness or made person ill(e g_.Second degree Auras•on .G� "I �' ;{,•!� t\t ,¢�p�E W
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<br /> Public•repnrdog bardea a,r dais cullecdon ofiafurmudoo is eadra ed to--age 14 miantes per resporce,indading dme to review Be sure to transfer these totals b the Summery page(Form-VOA)before you post It
<br /> the inamudoaa,aeardi and gachm•dm datuaredeJ.and cvu:plctea�revinv the cuDrrlicn ofuxfonoaelun_Pvsonc are�Oe required - e_
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<br /> AmJ.sia,Ruom N3a44,260 C nuiwdun P.venuc,NW,Lvauiingeon,DC.2027 0.Do not send the rompleeed Surma W Uvs uf5c� 1 aps or {i} (2) (3) (4) (5) (6)
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