Orange County NC Website
Browse       Search
0 <br /> 0 <br /> n <br /> c <br /> fn <br /> tom' <br /> m <br /> m <br /> 0 <br /> i m <br /> OSHAf <br /> s Form 300A (Rev_0912004) Note:You can type input into this form and save it. <br /> Because the forms in this recordkeeping package are"fillableiwritable" Year 20 13 <br /> 6 ��t� p� A p Injuries .g / PDF documents,you can type into the input foml fields and - <br /> Summary of Work-Related Injuries aa`�ei' ®11nesseS then saveyourinputsusin the free Adobe PDF Reader. U-S.Departmenivftabor � n <br /> g 000uparfonal Safety aQSd Honlut Adminlstnrtian <br /> Focm uppro.vd OMB no.1218-0176 <br /> All establishments covered by Part 7904 must complete this Summary page,even ifno work relafed injuries orillnesses occurred during the year <br /> Rememberto review the Log to verify that the entries are complete and accurate before completing this summary. n <br /> Using the Log,count the individual entries you made for each category Then write the totals below,malting sure you've added the entries from Establishment information m <br /> every pageofthelog.lfyouhadnocases,write'0." vour�rar:rme,�caa..,. Lomax Construction,Inc. m <br /> Employees,former employees,and their representatives have the right to review the OSHA Form 300 in its entirety.They also have limited access o <br /> v <br /> to the OSHA Form 307 or its equivalent See 29 CFR Part 1904.35,in OSHA's recordkeepfng rule,forfurther details on the access provisions for 8517-A Norcross Road W <br /> these forms Street <br /> W <br /> City Colfax State NC Zip 27235 <br /> of cij*se,s n <br /> Industry description(e.g.,Manufacture ofrnotor truck trailers) <br /> Total number of Total number of Total number ofcases Total number of General Contractors/Construction D <br /> 0 <br /> deaths cases with days with job transferor other recordable 00 <br /> away from work restriction cases Standard Industrial Classification(SIC),if known(e.g.,3717) 0 <br /> Q Q Q Q 1542 w <br /> OR D <br /> North American Industrial Classification(NAICS),if known(e-g.,336212) <br /> Total number of days Total number of days of job Employment information(ffyou don't have these figures,see the <br /> away from work transfer or restriction Worksheet on the next page to estimate) <br /> 0 U Annual average number ofempioyees 17 <br /> (K) (L) <br /> Total hours worked by all employees Iast year 36413 <br /> njury and 171hess Types <br /> Sign here <br /> Total number of_.. Knowingly falsifying this document may result in a fine <br /> {M) <br /> (9)Injuries d (4) Poisonings D I certify th ve exa ' d this document and that to the best of <br /> my kno e e s true,accurate,and mto <br /> (2)Skin disorders a (5) Hearing loss � PB� <br /> (3)Respiratory Co pany exc ve Title <br /> conditions (6) All other illnesses b �dfj� �� 13� <br /> Phone- ,- Date 1 4PI <br /> Post this Summary page from February 1 to April 30 of the year following dw year covered by We form. 'I"`�'''' �•" ' <br /> "`Sapp p'np�ut:: <br /> Public rcponing burden farthis collection ofinfammtiaa is ostimamd 10 avenge 50 mitwms per raapoase,including time m ms•icw tiro inabuctians,snatch ami gotherthe dam needed,and _ <br /> eompicm and nvivsv au:wllection afivfannation.Person are and required to respond to the collection of iaformadon ualus it displals a ouacnily valid OMB.—I number•Ifyou have nay <br /> --u about fins-rsii--or any od—azpeets of aria dam eollcctioa,contact Its Dlpmtment oFLab.r;OSHA Cur—ofSndstiml AnaL-is,Room Nd644,200 Coostimtioa Avcnuc,NW, <br /> Washington.DC 20210.Do not send the oomplctfA foam m ibis oflfoa <br />