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<br /> Attention.This form contains information relating to — o
<br /> OSHA's Form 300 (Rev at/aaon) employee e health and must be used in a manner that t
<br /> ■�� protects the confidentiality of employees to the extent Year 2013 [W„
<br /> Log of ll ork-belated Il!)ur%es and Illnesses occupational safety information is being used for — m
<br /> occupational sateEy and health purposes. US.Department mI Labor m
<br /> Oaovpaftaud lialaty and rleerea adminbbaGon W
<br /> You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness,restricted workactwy wpb transfer, Norm nppmred OMB no.1218-0176 0
<br /> 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 health (n
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<br /> carp professional.You must also record work-related injuries and illnesses that meet any ofthe specific recording criteria ltislad in 29 CFR Pan 7904.8 through 1904.72.Fesf tree to Btabrshmenrn0ma I2acanelli ConsttttC>tillll Sonf{i �
<br /> use two Enos for a single case ifyou need to.You must complete an lnjury and Illness krcfdent Report{OSHA Form 301)or equivalent form for each injury or illness recorded on this r Apex s NC m form.if you're not sure whether case Is recordable,rail your local OSHA office for help. r�i p _ W
<br /> Identify the person Describe
<br /> Classify the case
<br /> to
<br /> (A) (8) (C) (D) CHECK ONLY ONE bo.fn,ea.1, ,ase Enter the number v(
<br /> dews:the Injured or 1,,-„,1 ;� rc
<br /> Case Lmployec's name Job title Date of injury Where the Pveat occurred Describe injtay or illness,parts of body affected, III worker wax t .ira2 �Sd 00
<br /> no. (eg.,Aetdrrl or onset {egg Loading dock startle aid) and object/substance Hutt directly injured ,, v W
<br /> of illness or trade person 111(e.g.,Second degree twrit on •, `• t_ t 'r t M1Sr d}
<br /> right forearm from--dylene tordh) ` r Away On lob nit ' W
<br /> 2 from trarmar or
<br /> work rantriotlon ��y(y� (n
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<br /> No reported work related injuries or illnesses for 2013 ' ,� " ' t rya; 0( 0pl A f, m
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<br /> Public reporting bu idea for this Al—ioa of iniu—im is esdmattd to a rragr 14 mimuci pct response.including time to review Be Sure to transfer these foists to the Sv=wrypsge(Form 3004)before you past It 7
<br /> tLc imo•uttiom,seeds and tr ate data a edcd,and m>ere and re' g 3e •@ a c
<br /> gad: m p v�ewtbewllecann ofuiforwaticn PLKrOaa arC not required
<br /> u.n:cpund w W e wllectiun ufinfnrauzdun unlace itdisplay:xcurrcuay vafid OLIB onmrnl number.ll'ynu have auy wmmmsb; 7
<br /> about these esWa:nrs or any other a'pecn ordtis dn.collectuu.m.uan:US Deparonent ofLsbor.OSHA Ol&e urStauni.1 n h 5
<br /> ntnaysic,Rwm t4-3 644,200 Cunsdmtion Alcnve,N W,Washingdm,DC 20210.Do na seed the complaed furm>to fur office. Pegs 2 (1) (2) (3) (4) (5) (6)
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