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0 <br /> 0 <br /> c <br /> ch <br /> cQ' <br /> rn <br /> `m <br /> OSHA's Form 300 (Rey.0112004� 0 <br /> [Note:You can type input into this form and save it ntion:This farm contains information relating to rb tog of Mork=Related ecause the forms in this recordkeeping package are`fillable/writable- employee health and must be used in a manner that DF documents,you can ty pe into the input form fields and protects the confidentiality of employees to the extent Year 20 "�4 en save your inputs using the tee Adobe PnF Reader,In addition, possible while the information is being used for co n Jurpes and Illnesses e forms are programmed to auto calculate as appropriate <br /> occupational safety and health purposes. U.S.Depawrnenr of Labs <br /> •. ..:-,,..- Nere ;s<»xs a:.......r.t.:.m:„;aourr::act,= ...st r:tr„ns<«- tictlyPatea.s Salaty asad fiN7N AaYn+Htlfrsri e0 <br /> You must record information about every work-relsfed death and about every work-refaced injury orillness that involves loss of consciousness,resfricted mirk activity or�ob <br /> �NJ <br /> transfer,days a way 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 F«m apprm ed OMa no.l 2l a-o1. <br /> licensed health care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria Listed in 29 CFR Fart 1904.8 <br /> through 1904.12.Feel free to use two fines lore single case if you need to You must complete an Injury and Illness Incident Report(OSHA Form 3201 or Establsnmcriname Harris Bros Electric& Controls <br /> each injury or illness recorded on this farm.!f you're not sure whether a case is remrcfaWe,ea11 ) equivalent form for <br /> your local OSHAoifieeforhelp. pyy Durham slats NC 4� <br /> 0111 0 <br /> Classify <br /> Case F,m pioyee's name .cob title Dale of injury Where the event occurred De Eater the number or UNi <br /> no. scribe injury or illness,parts of body trays the irr' d or Serest the Nr jvr'aokmm o W <br /> Welder) or onset of (e.g.,Loadmg dock north end) affected,and objeea/substance that ill worker was: choose auto type of iffness: -1l <br /> illness directly injured or made person ill(e.g., <br /> (e.g.. 2110) Second degree burns on right jorrarnt from Remained at Work {M) N <br /> acetylene torch) o <br /> Oaps esr Jab trasader Other rea•rb Away On J--oob -9 e C O <br /> Death from or runtdeNnn able nesaa hem traussler or e� 5 v <br /> restriction 92 <br /> (G) (H) {t) 3 a:v <br /> (32) work res <br /> Reset (K) (L) (t) (Z) (3) (4) (5) ((W <br /> RWnhlEay rye �a <br /> -dam —days � 4„ � l � �m <br /> Rt3set !fir <br /> +r�ontli raav <br /> _f7aset-: <br /> ” manor r day }''► /''� /''''� <br /> .:Resat <br /> mot.1 day j7 ,�• + <br /> Reset r�wa ` <br /> i�r.� �' r.•+►` _tlayn _tlays � err <br /> .}�93et <br /> _days _data r <br /> monN laay (�/+� //Y�y fy�y <br /> ydeys `day$ ♦ r i { 1 <br /> Reset l <br /> month I day ' t '7: <br /> .:Reset: <br /> monm r nay f �^"� <br /> :Reset. <br /> 1. (7, _days _days . I, <br /> =nmlday r <br /> :1�9SBf _deya _days <br /> 1 <br /> mntnrday l - �daya ^days �, <br /> Page totals <br /> Public mWliag Lnw m fu this collccdm of information is estimated to average 14 mnusa Per rrspor ,including time to review She <br /> maa+m+ienr.acarr:h and g.ther the ding needed.acid eeenplcte and retie-the capacai of information.pgsons app not teq urnd to �• fr $ <br /> smpmd W the Y Odin as cif u Of thrown a w1l it displays a nam=atly valid Oluttl cdatrol nwnber If you have nay cmmca s aboW thee: <br /> ertimatea a nay oche aspens of this Jnla mlleaioq contact:US _ m _ <br /> N-3644.200 Constitution Avenue,NW,Washin Depc�of I.ahor,OSHA 13ffice of Statiatiul An.lysis,Room $��(e� tfu s a ��i @t!'.dflltt r i <br /> 6b4 DC 20210.too not send the rompleted fonms m this office, <br /> >�•?a? (1) (2) (3) (4) (s) (6) <br />