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0 <br /> 0 <br /> c <br /> in <br /> tom' <br /> rn <br /> m <br /> 0 <br /> m <br /> OSHA'S Form 300A (R=v.01/2004) — <br /> Year 20 14 W <br /> tl <br /> Summary of Work-belated Injures and Illnesses ��.Department of Labor m <br /> eontrpatlotx 1 W ty and H—tth AdmW t—tion FA <br /> F—approved OMBno.171801'6 0 <br /> Ur <br /> Ur <br /> All establishments covered by Fart 1904 must complete this Summary page,even ifno work-related injuries or Illnesses occurred during the year.Remember to review the Cog w <br /> to verily that the entries are complete and accurate before completing this summary. <br /> Using the Log,count the individual entries you made for each category.Than write the totals below,making sure you've added the entries from every page of the log.if you Establishment information M M had no cases,write'0." pp <br /> Employees,(ormerem r or eetaLG.lns,.,,t name Racanelll Construction South FA <br /> ployees,and their representatives hava the right In review the OSHA Form 300 in its en&ety.They also have limited access to the OSHA Form 301 or <br /> its equivalent.See 29 CFR Part 1904.35,in OSHA's mcordkeeping rule,for lurtherdeWs on the access provisions for these forms. 1001 Femberton HM e 202 00 O <br /> Stnet v <br /> City Apex stare NC zip 27502 co <br /> 00 <br /> w <br /> Total number of Total number of Total number of Total number of Industry dwcriprion(e.,;rmu(m,ema(mnw.t,,,rk uelrrz) � <br /> deaths eases with days caseswithjob other recordable General Contractors Commercial Construction m <br /> away from work transfer or restriction cases m <br /> Standard Industrial Cl=fication(SIG),ifkntmm(ag,3715) O <br /> _0 0 0 0 2 5 4 2 <br /> North American IndwtrLd Classification(NA1CS),ifknown(e.g,336212) <br /> Number of Days <br /> Total number of days away lbtal number of days of job I Employment information fffyou doWi ham Lh�i:eu�,fee he <br /> from work transfer or restriction Work5bee en tilt hark ofthis page w rnimate.) <br /> 0 0 Annual avenge nurnhcr of employers 5 <br /> ( <br /> K 6800 <br /> ) (L) Toni hours worked by all employees last yz-ar <br /> Injury and Illness Types Sign here <br /> Total n umber of._. Knowingly falsifying this document may result in a fine_ <br /> (M) 0 0 <br /> (t)Injuries (4)Poisonings <br /> I certify that C have e*ctmined this document and that to the best of my <br /> 0 (5)Hearing loss � knrlp�t ertn-ies azc e,accurate,and complete. <br /> (2)Skin disorders (5)All other illnesses 0 <br /> (3)Respiratory conditions 0 <br /> mpvryrr <br /> t 91.9, 363-3600. 1/5115 <br /> Post this Summary page from February 1 to April 30 of the year following the year covered by the form. m <br /> Public rot uthgbenien for this mllecana oFinfe mw.ion a nethmied to average 58 mirmtm per,response,is tnu fime to review the inalrucfior.m r h and g tha ate dk—eded,wd <br /> compkte end review the eo]loraonotinformoaon.P---not inquired to—poed to the no3l.U-ofintmndion anlese It Ii-plxv a osreadyveld OMBcontrolmtub..lryou have nny <br /> eommrmt�about these esamatrs or my other upend orrhis dofa coU cktut.contest:US Department of Labor,03HA 012tt f Swasticei Amdpk,Roo.N.3644,200 Canualuann benre,NMI. <br /> NV ihtngwn,DC 20210.Do nut—d Uu eompleied forme to this office <br />