(G) (H) (I) or (J), the first entry should be lined out and a new entry made. For ● Visits to a physician or other another job, medical treatment beyond first aid, or loss of consciousness. You 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,
● 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) 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 . S (1) (2) (3) (4) (5) (6) - 7 -
Worksheet to help you fill out form OK300A
- 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) The total Number of Cases recorded above in (1) Injuries (4) Poisonings G + H + I + J must equal total Injury & (2) Skin disorders (5) Hearing loss
Illnesses Types recorded left in Check if time cannot be determined Food service Farming Event occurred: before during after work shift Repair, installation or service of Cleaning, Maintenance of building, machines, equipment 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: 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 .S N P S E SS O
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