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 Oklahoma Department of Labor 
 PEOSH Division                                                                                         
 3017 N Stiles, Suite 100 
 Oklahoma City, OK 73105 

 OFFICIAL STATE BUSINESS 
 
 Public Sector Guidelines of Occupational 
 Injuries and Illnesses 

 Recordkeeping Year 20XX 
 
                               IMPORTANT NOTIFICATION BOOKLET 
                               
                              The Oklahoma Department of Labor’s Public Employee Occupational Safety & 
                              Health Division  (PEOSH) has issued revised  forms. A copy  of  the new 
                              recordkeeping forms package is included for your convenience. 



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 An Overview: Recording Work-Related Injuries 
                                                                                                                                                                      What do you need to do? 

 and Illnesses 
 The Oklahoma Occupational Health & Safety Standards Act (OOHSSA) requires all public sector employers with one or more employees to                                Within 7 calendar days after you receive 
                                                                                                                                                                    information about a case, decide if the case is 
 prepare and maintain records of all work-related injuries and illnesses. Use these definitions below when you classify cases on the OK300 Log.                     recordable     under       the     recordkeeping
 Definitions are consistent with the OSHA Recordkeeping regulations, which have been adopted, in part, by the Oklahoma Department                                   requirements. To do that, you must: 
 of Labor.                                                                                                                                                          1. Determine whether the incident is a new 
                                                                                                                                                                    case or a recurrence of an existing one. 
 The Log of Work-related Injuries and Illnesses        Work-relatedness is presumed  for injuries and         ●   tuberculosis infection as evidenced by a          2. Establish whether the  case was  work- 
 (OK300) is used to classify work-related injuries     illnesses resulting from events or exposures           positive skin test or diagnosed by a physician or     related. 
 and illnesses and to note the extent and severity of  occurring in the  workplace unless  an exception       other licensed health care professional after         3. Identify the nature of the injury or illness, 
 each case. When an incident occurs, use the Log to    specifically applies. See 29 CFR 1904.5(b)(2) for      exposure to a known case of active tuberculosis,      the part of the body affected and the object or 
 record specific details about what happened and       the exceptions. The work environment includes the      ●   an  employee's  hearing  test  (audiogram)        substance that caused harm to the employee. 
 how it happened.                                      establishment  and other  locations  where one or      reveals 1) that the employee has experienced a        4. Identify what medical treatment was 
                                                       more employees are working or are present as a         Standard Threshold Shift (STS) in hearing in one      provided and determine if the case is recordable 
 The Summary of Work-Related Injuries & Illnesses      condition of  their employment. See     29 CFR         or both ears (averaged at 2000, 3000 and 4000         according to the treatment provided or the 
 (OK300A) - shows the totals for the year in each      1904.5(b)(1).                                          Hz) and 2) the employee's total hearing loss level    diagnosis of a significant injury or illness. 
 category. At the end of the year, you must post the                                                          is 25 decibels (dB) or more above audiometric          
 Summary    in a visible location so that  your        Which work-related injuries and illnesses must         zero (also averaged at 2,000, 3,000, and 4,000        If the  case is  recordable, complete  a form 
                                                                                                                                                                    OK301 and enter the injury on form OK300. 
 employees are aware of the injuries and illnesses     be recorded?                                           Hz) in the same ear(s) as the STS. 
 occurring in their workplace. Employers must keep     Record those work-related  injuries and illnesses                                                             
 a separate Log and Summary for each establishment     that result in:                                        What is medical treatment?                            When filling out the Forms, keep in mind... 
                                                                                                                                                                    You must fill the forms out   completely and in 
 or site expected to be in operation for one year or   ● death,                                               Medical treatment means the management and            detail. 
 greater. Oklahoma Exception: Under 380:40-1-5,        ● loss of consciousness,                               care of a patient to combat a disease or disorder.     
 an establishment can include more than one            ● days away from work,                                 The following are not considered medical              You must enter a case number, however, you are 
 physical location, but  only if  the direct daily     ● restricted work activity or job transfer, or         treatments and are NOT recordable:                    allowed to  codify your  case numbers  in any 
                                                                                                              ●   visits to a doctor or health care provider        manner  you  find  appropriate,  so  long  as  each 
 supervision of all staff is the responsibility of one ● medical treatment beyond first aid.                  solely for observation or counseling,                 case number is unique. 
 common individual.                                                                                           ●   diagnostic     procedures,          including      
                                                       You must also record work-related injuries and         administering prescription medications that are       You must enter the employees' name, unless the 
 Note, your employees have the right to review your    illnesses that are significant (as defined below) or   used solely for diagnostic procedures, and            case meets the requirements  of a "Privacy 
 injury and  illness records and they must be          meet any additional criteria listed below. You must    ●   any procedure that can be labeled as first aid.   Case", in which case, you must enter the words 
 available for review by PEOSH Inspectors and          record any significant work-related injury or illness  (See below for more information about first aid.)     "Privacy Case" in lieu of the employee's name. 
 provided within  4 business  hours of the initial     that is diagnosed by a physician or other licensed                                                            
 request. Cases listed on the Log are not necessarily  health care professional. You  must record any         What is first aid?                                    In column F, you must enter three things: 
 eligible for workers compensation  or  other          work-related case  involving  cancer, chronic          If the incident required only the following types     1. the exact nature of the injury, 
 insurance benefits. Recording an injury or illness    irreversible disease, a fractured or cracked bone, or  of treatment, consider it first aid. Do NOT record    2. the part of the body affected, 
 on the Log does not mean that the employer or the     a punctured eardrum. See 29 CFR 1904.7.                the case if it involves only:                         3. what object  or substance  was that  harmed 
 worker was at fault  or  that a PEOSH or OSHA                                                                ●   using  non-prescription medications  at           the employee. 
 standard was violated. PEOSH Regulations are          What are the additional criteria?                      non- prescription strength,                            
 available at www.labor.ok.gov.                        You must record the following  conditions when         ●   administering tetanus immunizations,              Note: "knee pain"  or  "hurt back"  are not 
                                                       they are work-related:                                 ●   cleaning, flushing or soaking wounds on           acceptable descriptions of the injury. 
 When is an injury or illness considered work-         ● any needlestick or cut from a sharp object that      the surface of the skin,                               
 related?                                              is contaminated with another person's blood or         ●   using  wound coverings, such as                   Be specific. "Torn ACL, Left Knee, Fell from 
 An injury  or illness is considered to be  work-      other potentially infectious materials,                bandages,  Band-Aids™, gauze pads, etc.,              Ladder" is an appropriate entry. 
 related if an event or exposure in the work           ● any case requiring an employee to  be                using Steri- Strips™, or butterfly bandages,           
 environment caused or contributed to the resulting    medically removed under the requirements of a             using hot or cold therapy,                        Be sure to classify each injury or illness per the 
 condition or significantly aggravated a pre-existing  PEOSH or OSHA health standard,                                                                               instructions on the forms. 
 condition. 



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  using any totally non-rigid means of support,          a case of HIV infection,  hepatitis,  or           Classifying Illnesses                              ear at 2000,  3000 or  4000 hertz, and the 
 such as elastic bandages, wraps, non-rigid back       tuberculosis,                                          Be specific                                        employee's total hearing is 25 dB or more above 
 belts, etc.,                                             a needlestick injury  or cut from a sharp                                                             audiometric zero (also averaged at 2000, 3000, 
  using eye patches,                                  object that is contaminated with another persons'      Skin diseases or disorders                         and 4000 hertz) in the same ear(s). 
  using simple irrigation or a cotton swab to         blood or other potentially infectious materials (see   Skin diseases or disorders are illnesses involving  
 remove foreign bodies not embedded in or adhered      29 CFR 1904.8 for definitions), and                    the worker's skin that are caused by work          All other illnesses 
 to the eye,                                              other     illnesses,    if the  employee           exposure to chemicals,  plants,  or other          Examples:    Heatstroke,   sunstroke,  heat
  using  irrigation, tweezers or cotton swab  or      independently and voluntarily requests that his or     substances.                                        exhaustion, heat stress and other effects of 
 other simple means to remove splinters or foreign     her name not be entered on the log.                                                                       environmental heat; freezing, frostbite  and 
 material from areas other than the eye,                                                                      Examples: Contact dermatitis, eczema or rash       other effects    of  exposure       to lower
  using finger guards,                                You must not enter the employee's name on the Log      caused by  primary irritants  and sensitizers or   temperatures; decompression sickness; effects 
  using massages,                                     for these cases. Instead, you must enter "Privacy      poisonous plants; oil  acne;  friction blisters,   of ionizing radiation (isotopes, x-rays, 
                                                       Case" in  the space normally  used for the 
  drinking fluids to relieve heat stress.                                                                    chrome ulcers; inflammation of the skin.           radium); effects  of non-ionizing radiation 
                                                       employee's name (Column B).  You must keep a                                                              (welding  flash, ultra-violet rays, lasers); 
                                                       separate confidential list of the case numbers and     Respiratory conditions                             anthrax; bloodborne pathogenic diseases, 
 How do you decide if the case involved restricted     employee  names for the establishment's privacy        Respiratory conditions are illnesses associated    such as AIDS, HIV, hepatitis B or hepatitis C; 
 work?                                                 concern cases so that you can update the cases and     with breathing hazardous  biological  agents,      brucellosis;  malignant or  benign tumors; 
 Restricted work activity occurs when, as the result   provide information  to  the government, if            chemicals, dust, gases, vapors, or fumes at work.  histoplasmosis; coccidioidomycosis. 
 of a work-related injury or illness, an employer or   requested.                                                                                                 
 health care professional keeps or recommends 
                                                        
 keeping, an employee from  doing the routine                                                                 Example:  Silicosis, asbestosis, pneumonitis,      When must you post the Summary? 
                                                       If you  have a reasonable basis to believe that 
 functions of his or her job or from working the full                                                         pharyngitis, rhinitis or acute congestion;         You must post the Summary only -- not the Log 
                                                       information describing the  privacy concern case 
 workday   that the employee would  have been                                                                 farmer's  lung, beryllium  disease, tuberculosis,  --  by February  1st of  the year  following the 
                                                       may be personally identifiable,  even though the 
 scheduled to work before the injury or illness                                                               occupational asthma,       reactive airways        year covered by this form and keep it posted 
                                                       employees name has been omitted, you may use 
 occurred.                                                                                                    dysfunctional syndrome (RADS), chronic             until April 30th of that year. 
                                                       discretion in describing the injury or illness or both obstructive  pulmonary     disease  (COPD),         
                                                       on the OK300 and OK301 forms. You must enter           hypersensitivity pneumonitis, toxic inhalation     How long  must you keep the Log, 
 How do you count the  number of  days of              enough information to identify  the cause of the       injury, such as metal fume fever, chronic          Summary, or the Individual Injure/Illness 
 restricted work activity or number of days away       incident and the general severity of the injury or     obstructive  bronchitis,   and           other     Report on file? 
 from work?                                            illness, but you need not include the details of an    pneumoconiosis.                                    You must  keep the  Log and    Summary for 5 
 Count the  number of calendar days, including         intimate or private nature.                                                                               years following the year to which they pertain. 
 weekends and holidays (even if the employee was                                                              Poisoning                                          These records must be available for review at 
 not scheduled to work), that the employee was on 
 work restrictions or was away from work as a result   What if the outcome of the case changes?               Poisoning includes disorders evidenced by          all times.  Individual Injury/Illness Reports 
 of the injury or illness. Do not  count the day on    If the  outcome or extent  of an  injury  or illness   abnormal concentrations of toxic substances in     must be maintained for  30 years after the 
 which the injury or illness occurred. Begin counting  changes after you have recorded the case, simply       blood, other tissues, other bodily fluids, or the  employee is no longer employed by the State 
 the days away from the day    after   the incident    delete, or draw a line through the  original entry.    breath that are caused by the ingestion  or        of Oklahoma with any Public Sector employer. 
 occurs.                                               Then write the  new entry where it  belongs.           absorption of toxic substances into the body.       
                                                       Remember, you  need to record  the most serious                                                           Do you have to send in these forms at the 
 If a single injury or illness involves both days away outcome for each case.                                 Examples: Poisoning by lead, mercury,              end of the year? 
 from work and days  of restricted work activity,                                                             cadmium, arsenic or other metals; poisoning by     All Public Employers must provide records as 
 enter the total number of days for each.              Classifying injuries                                   carbon monoxide, hydrogen sulfide, or  other       part of the Annual Public Sector Survey, by 
                                                                                                              gases; poisoning by  benzene, benzol, carbon,      submitting the information online, at 
 You may stop counting days of restricted work or      An injury is any wound or  damage to the body          tetrachloride, or other organic  solvents;         www.ok.gov/odol/public-sector-survey/ or by 
 days away from work once the total of either, or      resulting from an event in the work environment.       poisoning by insecticide sprays, such as           submitting   copies     of     the  requested
 the combination of both, reaches 180 days.                                                                   parathion or lead arsenate; poisoning by other     information. Participation in  the Annual 
                                                       Examples:  Cut, puncture,  laceration, abrasion,       chemicals such as formaldehyde.                    Public Sector Survey is mandatory. Failure to 
 Under what circumstances should you NOT               fracture, bruise, contusion, chipped  or broken                                                           respond will result in a PEOSH inspection. 
 enter the employee's name on form OK300?              tooth, amputation, insect bite,  electrocution or      Hearing loss                                        
 You must consider the following injuries or illnesses thermal, chemical, electrical or  radiation burn.      Noise-induced  hearing loss is defined for         How can we help you? 
 to be privacy concern cases:                          Sprain and strain injuries to muscles, joints and      recordkeeping purposes as a change in hearing      If you have questions about how to fill out the 
  an injury or illness to an intimate body part or    connective tissues are classified as injuries when     threshold relative to the baseline audiogram of    Log, call us at (405) 521-6140 or toll free at 1-
 to the reproductive system,                           they result from a slip, trip, fall or other similar   an average of 10 (decibels) dB or more in either   888-269-5353. 
  an injury or illness resulting from a sexual        accidents. 
 assault, 
  a mental illness, 



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How to Fill Out the OK300 Log of Work-Related Injuries and Illnesses 
 
The Log is used to classify work-related injuries 
and illnesses and to note the extent and severity 
of each case. When an incident occurs, use the 
Log to  record specific details about what 
happened and how it happened. 
 
If your agency or entity has  more than one 
establishment or site, you must keep separate 
records for each  physical location that is 
expected to remain in operation for one year or 
longer. 
 
Can an establishment include more     than one 
physical location? 
Yes, but only if the direct daily supervision of all 
staff is the responsibility  of one common 
individual. {See   380:40-1-5(a)(6)  of the 
Oklahoma Occupational  Health  & Safety 
Standards.} 
 
The Summary -- shows the work-related injury 
and illness totals for the year in each category. At 
the end of the year, count the number of incidents 
in each category and transfer the totals from the 
Log to the Summary. The highest ranking official 
or other official must review and certify the 
Summary. From February 1  stto  April 30   theth
following  year, post the Summary in a visible 
location so that your employees are aware of the 
injuries and  illnesses occurring in their 
workplace. 
 
You do not post the Log. You only post       the 
Summary at the end of the year. 



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  Recording Criteria                                                                                                               Changes in Extent of or Outcome of Injury or Illness                                 
 
  (a) Basic Requirement. You must consider an injury or illness to meet the               Cases are not recordable:               If, during the five-year period in which the Log is retained, there is a change in 
 general recording criteria, and therefore to be recordable, if it results in any of                                              an extent and outcome of an injury or illness which affects entries in columns 
                                                                                           
 the following: death, Days  wayA from work,  estrictedR work or  ransferT to                                                     (G) (H) (I) or (J), the first entry should be lined out and a new entry made. For 
                                                                                          
 another job, medical treatment beyond first aid, or loss of consciousness. You             Visits to a physician  or  other 
                                                                                                                                  example, if an injured employee at first required only medical treatment with 
                                                                                          licensed health care  professional 
 must also consider a case to meet the general recording criteria if it involves a        (LHCP) solely for observation or        no lost work days but later lost days away from work, the check in column (J) 
 significant injury or illness diagnosed by a physician or other licensed health          counseling.                             should be lined out, and a check entered in column (H) and the number of days 
 care professional, even if it does not result in death, days away from work,              Diagnostic procedures, such as x-     away from work entered in column (K). 
 restricted work or job transfer, medical treatment beyond first aid, or loss of          rays and  blood tests, including the     
 consciousness.                                                                           administration     of prescription      In another example, if an employee with an occupational illness with days away 
                                                                                          medications solely for diagnostic       from work, returned to work, and then died of the illness, any entries in column 
  (b) Implementation. How do I decide if a case meets one or more of the                  purposes (e.g., eye  drops to  dilate   (H) should be lined out and the death entered in column (G). 
 general recording criteria?                                                              pupils).                                 
                                                                                            First Aid only (see the complete      The entire entry for an injury or illness should be lined out if later found to be 
                                                                                          
                                                                                          list on pages 2-3)                      non-recordable. This would include for example: an injury which is later 
 A work-related injury or illness must be recorded if it results in one or more of                                                determined not to be work-related or which was initially thought to involve 
 the following:                                                                                                                   medical treatment but later was determined to have involved only first aid. 
  1)  Death,                                                                                                                       
  2)  Days away from work, 
  3)  Restricted work or transfer to another job,                                                                                  Diagnosis of Significant Injury or Illness                                           
  4)  Medical treatment beyond first aid,                                                                                          
  5)  Loss of consciousness,                                                                                                      Any serious or significant work-related disorder that is  diagnosed by a 
  6)  A significant injury or illness diagnosed by a physician or other                                                           Physician or  other  icensed L     ealth H are CroviderP     and/or identified by  a 
      licensed health care professional.                                                                                          positive medical test. These include work-related cases involving cancer, 
                                                                                                                                  chronic irreversible disease, a fractured or a cracked  bone or  a punctured 
  Recordkeeping Criteria Decision Tree                                                                                            eardrum. 

                                                                                          Calculating the Incident Rate                                                                                                 
 
                                                                                         You can compute your entities incident rate (IR) by utilizing the following formula. 
                                                                                          
                                                                                           Total number of injuries     X          200,000                # of hours worked by all             =      Incident 
                                                                                                  and illnesses                                                      employees                            rate 
                                                                                                                                                                                                           
                                                                                            ________________            X          200,000                ÷_______________                     =      _______ 
                                                                                          
                                                                                         What can I compare my incident rates to? 
                                                                                         Each year the Oklahoma Department of Labor analyzes data from the Annual Public Sector Survey. For details on the State’s 
                                                                                         Incident Rate, visit the ODOL website listed below. 
                                                                                          
                                                                                         For additional information, you may call (405) 521-6140 or 1-888-269-5353 or visit our web site at: 
                                                                                          
                                                                                         www.labor.ok.gov. 
 
  Figure 1 - Ask yourself each of these questions to determine if a case is recordable. 



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      OK300 -- Log of Work-Related Injuries & Illnesses                                                                   ATTENTION: This form contains information relating to employee health and                                                                                                                                       Year ______ 
                                                                                                                          must be used in a manner that protects the confidentiality of employees to the extent 
      Oklahoma Department of Labor                                                                                        possible while the information is being used for occupational safety and health 
                                                                                                                          purposes. 
      405-521-6140; 888-269-5353; www.labor.ok.gov 
                                                                                                                                                             
 You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness,               
 restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record significant work-                Establishment 
 related injuries that are diagnosed by a physician or licensed health care professional (PHLCP). You must also record work-related injuries                  
 and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to use two (2) single lines          Physical Location 
 for a single case if you need to. You must complete an Injury & Illness Incident Report (form OK301) for each injury or illness recorded on this 
 form. If you’re not sure whether a case is recordable, call the Oklahoma Department of Labor for help at 1-888-269-5353.                                     
                                                                                                                                                             City, State, ZIP                                                                                                                                                                                                                                                                                   
  
          Identify the person                                  Describe the case                                                                                                                 Classify the case 
                                                                                                                                                                                                 Enter number of days 
 (A)  (B)             (C)                 (D)              (E)                                                 (F)                                    CHECK ONLY ONE box for each case based     injured or ill worker                   (M) Choose one type of illness: 
 Case Employee's Name Job Title (e.g., Date of injury or   Where the event occurred (e.g.                      Describe injury or illness, parts of   on the most serious outcome for that case:        was:                                                                                                      Respiratory condition                                                                                              All other illnesses 
 No.                  Welder)          onset of illness    Loading dock north end)                           body affected, and object/substance      Death  Days    Remained at work            Away   On job                                         Skin disorder                                                                                Poisoning                  Hearing loss 
                                                                                                             that directly injured or made person ill        away                                from   transfer              Injury 
                                                                                                               (e.g. Second degree burns on right 
                                                                                                               forearm from acetylene torch)                 from    On job      Other           work        or 
                                                                                                                                                             work    transfer    recordable             restriction 
                                                                                                                                                                     or          cases 
                                                                                                                                                                     restriction                                                                                                                                                                                                                                                                              
                                          (D)                                                                                                                                                    (days) (days)                                                                                                                                                                                                                                                
 (A)  (B)             (C)              MM     DD           (E)                                                 (F)                                    (G)    (H)     (I)         (J)             (K)         (L)                     (1)                             (2) (3)                                                                                  (4)                           (5)                                                          (6)  
                                                                                                                                                                                                                                                                                                                                                                                                                                                              
 Public reporting burden for this collection of information is estimated to average 15 minutes per response,       Page Totals:                                                                                                                                                             Respiratory condition                                                                                                All other illnesses                           
 including time to review the instruction, search and gather the data needed, and complete and review the                                             (G)    (H)     (I)         (J)             (K)         (L)                         Skin disorder                                                                                    Poisoning               Hearing loss 
                      collection of information.                                                               Ensure totals to the Summary page (Form 300A) are accurate before you post it.                          Injury                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                              
                              RETAIN FOR YOUR RECORDS     RECORDS MUST BE MAINTAINED FOR A MINIMUM OF FIVE YEAR.                                                                                                       (1)               (2)                             (3)                                                              (4)                     (5)                           (6)                                                           



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        Worksheet to help you fill out form OK300A - Summary of Work-Related Injuries & Illnesses                                                         Year ______ 
        Oklahoma Department of Labor                                                                                                                       
        405-521-6140; 888-269-5353; www.labor.ok.gov 
                                                                                                                                                           Optional 

At the end of the year, you are required to enter the average number of employees and the total hours worked by your employees on form OK300A. If you don't have these figures, 
you can use the information on this page to estimate the numbers you will need to enter on form OK300A at the end of the year. 
 
How to figure the average number of employees who worked for your                             
establishment:                                                                                
                                                                                              
Step 1: Add the total number of employees your establishment paid in all pay periods         The number of employees paid in all pay periods = __________ 
during the year.  Include all  employees;  full-time, part-time, temporary, seasonal,         
salaried, and hourly.                                                                        Divided by 
                                                                                              
Step 2: Count the number of pay periods your establishment had during the year. Be           The number of pay periods during the year = __________ 
sure to include any pay periods when you had no employees.                                    
                                                                                             Rounded to the next whole number = __________ 
Step 3: Divide the number of employees by the number of pay periods.                          
 
Step 4: Round the  answer   to the next highest  whole number.  Write  the  rounded 
number in the blank marked Annual average number of employees. 
 
For example, a public entity figured its average employment this way: 
                                                                                              
   For pay period               Number of employees Paid                                     Number of employees paid = 830 
        1                                10                                                   
        2                                0                                                   Number of pay periods = 26 
        3                                15                                                   
        4                                30                                                  830  ÷26 = 31.92 
        5                                40                                                   
                                                                                         31.92 rounds to 32 
        24                               20                                                   
        25                               15                                                  32 is the annual average number of employees 
        26                               830 

How to figure the total hours worked by all employees: 
 
Include the hours worked by salaried, hourly, part-time, and seasonal workers, as well as hours worked by other workers subject to day-to-day supervision by your establishment 
(e.g., temporary help services workers). 
 
Do not include vacation, sick leave, holidays, or any other non-work time, even if employees were paid for it. If your establishment keeps records of only the hours paid or if you 
have employees who are not paid by the hour, estimate the hours that the employees actually worked. 
 
If this number is not available, you can use this optional worksheet to estimate the number. 
 
                      Optional Worksheet 
                       
                       Find the number of full-time employees in your establishment for the year. 

 *                     Multiply by the number of work hours for a full-time employee per year. 
                       
                                 This is the number of full-time hours worked. 
 +                     Add the number of any overtime hours as well as the hours worked by other 
                      employees (part-time, temporary, seasonal). 
                       
                       Round the answer to the next  highest whole number.  Write the rounded 
                      number in the blank marked Total hours worked by all employees last year. 
                       



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                                                                                                                                                                                                 Year ______
                    OK300A -- Summary of Work-Related Injuries & Illnesses                                                                           Mandatory 
                    Oklahoma Department of Labor 
                    405-521-6140; 888-269-5353; www.labor.ok.gov 

 Section 1: Establishment Information 
                                                                                                                                                                                                                        
 Establishment                                                                                                                                                                                                       Facility ID 
                                                                                                                                              
 Location                                                                                                                                   Physical Address 
                                                                                                                                              
 Mailing Address                                                                                                                            Physical City 
                                                                                                                                                                                                                                       
 Mailing City,     State     ZIP                                                                                                              Mailing State           Mailing Zip                                     Telephone 
   
 Instructions: All establishments covered by Part 1904 must complete the questions below, even if no work-related injuries or illnesses occurred during the year. Remember to review the OK300 Log to 
 verify that the entries are complete and accurate before completing this summary. Using the Log, count the individual entries you made for each category. Then write the total below, making sure you've 
 added the entries from every page of the Log. If you had no cases, enter "0". Employees, former employees, and their representatives have the right to review the OK300 Log in its entirety. They also have 
 limited access to the OK300 Log or its equivalent. See 29 CFR Part 1904.35, in OSHA's recordkeeping rule, for further details on the access provisions of these forms. If you have questions or need 
 assistance, call the Oklahoma Department of Labor at 1-888-269-5353. 
                                                                                                                                                                                                                                        
 1. Annual average number of employees:                                                                      2. Total hours worked by all employees last year:                                                                          
                                                                                                                                                                                                                                        
 3. Check any conditions that might have affected your answers to questions 1 and 2 above during this reporting year:                                                                                                                   
               Strike or lockout                              Natural disaster or adverse weather conditions                                Other reason:                                                                               
               Shutdown or layoff                             Shorter work schedules or fewer pay periods than usual                        Nothing unusual happened to affect our employment or hours figures.                         
               Seasonal work                                  Longer work schedules or more pay periods than usual                                                                                                                      
 4. Did you have ANY occupational injuries or illnesses during this reporting year                                                                                                                                                      
               Yes. Go to Section 2: form OK300A -- Summary of Work-Related Injuries and Illnesses …                                        No. Go to Section 3: Contact Information and Certification…                                 
                                                                                                                                                                                                                                        
 Section 2: OK300A -- Summary of Work-Related Injuries and Illnesses,                                                                                           YEAR: ______                                                            
 Number of cases                                                                                                                                                                                                                        
 Total number                    Total number of cases with    Total number of            Total number of                                                                                                                               
   of deaths                     days away from work           cases with job             other recordable 
                                                               transfer or                cases                                                                                                                                         
                                                               restriction                                                             For each case in Column G or H complete form OK301  – 
                                                                                                                                         Injury & Illness Report -- Case Information                                                    
                                                                                                                                                                                                                                        
    (G)                                (H)                     (I)                         (J)                                                                                                                                          
                                                                                                                                                                                                                                        
 Number of days                                                                                                                                                                                                                         
   Total number of                                            Total number of days of                                                         Facility Incident Rate Calculator                                                         
    days away                                                 job transfer or restriction 
    from work                                                                                                           Injuries/Illness      Multiplier          Employees Hours                                     Incident Rate     
                                                                                                                                         *    200000           ÷                                 =                                      
    (K)                                                        (L)                                                                                                                                                                      
                                                                                                                                                                                                                                        
 Injury & Illness types                                                                                                                                                                                                                 
 Total number of…                                                                                            (M)                                                                                                                        
          (1) Injuries                                                                    (4) Poisonings                                                         The total Number of Cases recorded above in                            
                                                                                                                                                                  G + H + I + J must equal total Injury &  
          (2) Skin disorders                                                              (5) Hearing loss                                                            Illnesses Types recorded left in                                  
                                                                                                                                                                                M (1 + 2 + 3 + 4 + 5 + 6). 
          (3) Respiratory condition                                                       (6) All other illnesses                                                                                                                       
                                                                                                                                                                                                                                        
 Section 3: Contact Information and Certification                                                            (Knowingly falsifying this document may result in fines, legal actions, or both.)                                          
 I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate and complete.                                                                                                         
                                                                                                                                                                                                                                        
    Name and signature of Agency Executive/Official                                       Telephone                                           Ext.                                             Fax Number                               
                                                                                                                                                                                                                                        
                                 Title                                                                                          E-Mail                                          Today's Date (MM/DD/YYYY)                               
                                                                                                                                                                                                                                        
 Public reporting burden for this collection of information is estimated to average 50 minutes per response, including time to review the instructions, search and gather the data needed, and complete and review the collection of    
 information. If you have any comments about these estimates or any other aspects of this data collection, contact: Oklahoma Department of Labor, 3017 N Stiles, Suite 100, Oklahoma City, OK 73105; 1-888-269-5353. 
                                                                                                                                                                                                                                        
                                                               Post this Summary page from February 1st to April 30th,                                         ______                                                                   
                                                                                                                                                                                                                                        



- 9 -
                                                                                                                                                                            Year ______ 
              OK301 – Individual Injury & Illness Report -- Case Information                                                             Mandatory 
              Oklahoma Department of Labor 
              405-521-6140; 888-269-5353; www.labor.ok.gov 

 Case Information                                                                                                                                                           Facility ID 
  YOU MUST COMPLETE FORM OK301 FOR EACH RECORDABLE CASE. When submitting for the Public Sector Survey, only include the form OK301 page(s) for incidents resulting in Cases 
                                                                      with Days Away from Work (column H) or Death (column G). 
                                                                                                                                                                                                            
   Case number                   Employee's                    Job Title                      Date of Injury/Illness     Number of days                      Number of days of job transfer                 
    from Log                      name                                                                                  away from work                                      or restriction                  
                                                                                                    (column D) 
    (column A)                   (column B)                    (column C)                     MM     DD    YYYY                (column K)                                   (column L)                      
                                                                                                                                                                                                            
                            Tell us about the Employee                                                                  Tell us about the Incident                                                          
 1. Check the category which best describes the employee's regular type of job or work:           6. Time employee began work:                                                    am                pm      
 (optional)                                                                                                                                                                                                 
              Construction                                 Healthcare                             7. Time of event:                                                               am                pm      
              Sales                                        Delivery or driving                                       OR                  Check if time cannot be determined                                 
              Food service                                 Farming                                   Event occurred:           before                during           after     work shift                  
              Repair, installation or service of 
              machines, equipment                          Cleaning, Maintenance of building,                                                                                                               
                                                           grounds 
                                                                                                  8. What was the employee doing just before the incident occurred? Describe the activity as well as        
              Office, professional, business, or           Material handling (e.g. stocking,      the tools, equipment, or material the employee was using. Be Specific. Examples: "climbing a ladder       
              management staff                             loading/unloading, moving, etc.)       while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry." 
                                                                                                                                                                                                            
              Product assembly, product                    Other:                                                                                                                                           
              manufacture                                                                           
                                                                                                                                                                                                            
 2. Employee's race or ethnic background: (optional-check one or more)                            9. What happened? Tell us how the injury or illness occurred. Examples: "When ladder slipped on wet       
                                                                                                  floor, worker fell 20 feet"; Worker was sprayed with chlorine when gasket broke during replacement"; 
              American Indian or Alaska Native                                                    "Worker developed soreness in wrist over time."                                                           
              Asian                                                                                                                                                                                         
              Black or African American                                                                                                                                                                     
                                                                                                    
              Hispanic or Latino                                                                                                                                                                            
              Native Hawaiian or Other Pacific Islander                                                                                                                                                     
              White                                                                               10. What was the injury or illness? Tell us the part of the body that was affected and how it was         
                                                                                                  affected; be more specific than "hurt," "pain," or "sore." (These are symptoms, not injuries.) Examples: 
              Not available                                                                       "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."                                         
                                                                                                                                                                                                            
 3. Employee's age:                     AND                                                                                                                                                                 
                                                                                                    
                                  Date of Birth            MM           DD      YYYY                                                                                                                        
                                                                                                                                                                                                            
 4. Employee's date hired:                                                                        11. What object or substance directly harmed the employee? Examples: "concrete floor";                    
                                                                                                  "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank. 
                                  MM             DD     YYYY                                                                                                                                                
                                                                                                                                                                                                            
 5. Employee's sex:                                                                                                                                                                                         
                                                                                                    
              Male                                                                                                                                                                                          
              
              Female                                                                                                                                                                                        
                                                                                                  12. Was the employee treated in an emergency room?                        Yes                     No      
 Completed by                                                                                                                                                                                               
 Title                                                                                            13. Was employee hospitalized overnight as an in-patient?                 Yes                     No      
 Phone                                                                                                                                                                                                      
 Date Completed                                                                                   14. If the employee died, record date of death:                                                           
                                                                                                                                                                      MM      DD                 YYYY       
                                  RETAIN FOR YOUR RECORDS     RECORDS MUST BE MAINTAINED FOR A MINIMUM OF FIVE YEAR.                                                                                        
 N                          P                              S                                      E                            SS                                     O                                     
                                                                                                                                                                                                            






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