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<br /> Attention:This form contains information relating to
<br /> OSHA's Fofm 300 (Rev.0112004) employee health and must be used in a manner that''
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<br /> rotects the confidentiality of employees to the extent Year 20 14.
<br /> ®� possible while the Information is being used for °
<br /> ®g of Work-Related InJuries and Illnesses occupational safety and health purposes, tf s. ry..rtment of Labor o
<br /> i record (jeeup.tiom75afaty and aaal[h Admlolstratlon W
<br /> You must ln/ormation about every work-related death and about every work-relaledinjury crillness that involves loss of consciousness restricted work acffvtrbrJob transfer, r',i mr uppro,'ed 0hiB no.121 M 17
<br /> days a way from work,ormedical Use tmentbeyondArst aid.You musta Isom cord signiNcantwork-releted injuries and B lnessos that atadia nosedb a ••-• - °
<br /> g y physician 4 Ilbensed healri ~'
<br /> careprofessional You must also record work-refutedst Injuries and/Ansley that meet any idthespecific recording criteria listed in le 29 CFR Part 1904.8 through l9oa.12 Fes/free to Fsrahusgmonrneme Lomax Construction, Inc. 0
<br /> use two ouY loot single case if yea need to.You must complete an Injury and lUness Inc dent Report(OSHA Form 301)orequ ve/ent for toreach injury orillness recorded on this -- rn
<br /> form.lfyou're not sure whethera case is recordable,cailyourlocalOSHAofrcelorhelp. c+rr`Colfax crate N� A
<br /> Identify person - m
<br /> (A) (al (C) Describe(D) (� F sn2or tha nurser of tF.:. "t,;' ."...... W
<br /> () daya the Infused or =:2Chock thq?'(iljliry?c4lymq
<br /> Cnm Employee's mme jnh ttte Date of injury Where die event occurred Describe injury or illness,parts of body iiff.a da III warkar was: -i,ehoaaa no d o%Ilinq fi.i; W
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