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0 <br /> 0 <br /> c <br /> cQ' <br /> M <br /> m <br /> OSHA's Form 300 (Rev.0112004) 0 <br /> Wrote:You can type input into this form and save et. [employee ttention:This form contains information relating to <br /> Lo of Work-Related Because the forms in this recordkeeping package are"fillablelwritable" health and must be used in a manner that 9 PDF documents,you can type into the input form fields and otects the confidentiality of employees to the extent Year 20 13 to <br /> then save your inputs using the tree AdoGe PI.) Reader.In addition, ssible while the information is being used for to Ina�urles and Illnesses the forms are programmed to auto-calculale as appropriate. cupatlDnal safety and health purposes, o <br /> t"t o° <br /> U.S.i�pattrlreetee or La <br /> Occt4atlo.tal Safety and if arth Admnus <br /> You must record information about every work-related death and about every work-related injury or illness that involves loss ofconsuousness,restricted work actit4ty or job Fo;a po o o�la no.I2laAl lv <br /> transf'r,days away from work,or medical treatment beyond first aid.You must also record significant work related injunes and illnesses that are diagnosed by a physician or <br /> licensed health care professional.You must also record work-related injuries and illnesses that meet any ofthe specific recording criteria listed in 29 CPR Part 1904.8 Es[abhshmentneme Farris Bros Electric&Control:c) <br /> through 1904.12.Feet free to use two lines for a single case if you need to.You must complete an injury and Illness Incident Report(OSHA Form 301)orequivalent form for <br /> each injury or illness recorded on this form.It you're not sure whethere case is recordable,tall your local OSHA office for help. NC T <br /> c,,,Durham stale 4� <br /> W <br /> ao <br /> . �- rr <br /> W <br /> (A) y. {e) (C) f0} (P) (F) ' ' Enter the number or select the°In fV <br /> Case tSm li�ycc's name Job title Date of in'ur Where the event occurred Describe injury or illness, arts or body d+y+u°irti�d a !wY'column Cn <br /> P 1 Y f rY P y based I !!worker was chows cue type of illness .n <br /> na. (saga,welder) or Dose[of (saga,Loading dock north end) affected,and object/substance that ry TI <br /> dines. directly injured or made person JI(e.g., " - ---- ••,res. ,...a ...:.gar�. =;ri <br /> (saga, vfo) <br /> Second degree burns on rightforearm from Rdaw mod at work t ) <br /> dcetylene torch) array <br /> s Jos trasBea OSher record. {q 2 e'er 2 :O <br /> Death from werfc ne rerbiatlnn am*uw work wsLrietien S c4$ ° 'Tl <br /> (G) (H) (I) (J) (K) {L) (1) (2) (3) �(4) (5) W <br /> Reset i_ <br /> m <br /> (7" <br /> — month!day f"' /'''� y''� }''''� <br /> �BSet 1 - _days _days i. l. .- [ - r r l <br /> R88eI 1— l.... 1. - - _days _days c 1 l r r `. <br /> — montfilday r f"� /''� <br /> ttU � <br /> lt3sBt. 1— 1., i , \.. _soya _days r r r [ r F <br /> f"'� <br /> - nih 1 day "'��_+.. yew /� �r per �«r <br /> Reset r r _day. _day. [ l L l L 1. <br /> In6fM 1 dpV .. <br /> —– montnrday r Ca � .....d.ys _day. r 4�r. /ry /rte► r fir+ <br /> Reseti i_ ti.: r 1,,; _days days r t .' L [ r l. <br /> — rramh/day <br /> Reset l <br /> —In i day r ,.C� r r r r r r <br /> /`► y"''^� _d"ra _day. <br /> FZB9el 1— r l r' _day. _days (7 <br /> — �nmraar t r r, r, i �. <br /> Pays totals JOB <br /> Public Mira Wrd=for thu wlW'On of ide bliOn i3 csti tcdto avaragc la miautesperrupoase,including time to <br /> manididm,smeh and gather the deli needed,uW oomplee and teview the ealleeiide of infotmalidn.persons ass not wg4md to <br /> reapnW an tk eoUxtion of inf—tatiun un)ev it disomp a cunrntly,valid OMB waanl number.If you lvavc any canmeraa.boot these <br /> catimaka or any other aspcas of this data rolledwn,colmlecl:US apttttneat of Labor.OSHA Office of Statistical Aoa4ysis,Roam �. ,.'$dY@�]] � s as, b4$FOMI a <br /> N-3644,zoo constitution Avenue,NW,Washington,DC 202 10.Do not send the completed tome to this of£x Page et 1 (1) (2) ($) (4) (5) (fi) <br />