Year 20
SUMMARY OF WORK-RELATED INJURIES AND ILLNESSES Michigan Department of Licensing and Regulatory Affairs
Michigan Occupational Safety and Health Administration (MIOSHA)
Form Approved OMB No. 1218-0176
All establishments covered by Public Law of 1970 (P.O. 91-596) and Michigan Occupational Safety and Health Act 154, P.A. 1974, Part 11,
Michigan Administrative Rule for Recording and Reporting of Injuries and Illnesses, must complete this Summary page, even if no injuries or
illnesses occurred during the year. Remember to review the Log to verify that the entries are complete and accurate before completing this
summary. You may be fined for failure to comply.
Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you've added the entries from Establishment information
every page of the log. If you had no cases write "0."
Employees former employees, and their representatives have the right to review the MIOSHA Form 300 in its entirety. They also have limited Your establishment name
access to the MIOSHA Form 301 or its equivalent. See Part 11, R408.22135 Rule 1135, in MIOSHA's Recordkeeping rule, for further details on
the access provisions for these forms. Street
Number of Cases City State Zip
Industry description (e.g., Manufacture of motor truck trailers)
Total number of Total number of Total number of cases Total number of
deaths cases with days with job transfer or other recordable
away from work restriction cases Standard Industrial Classification (SIC), if known (e.g., SIC 3715)
(G) (H) (I) (J) OR North American Industrial Classification (NAICS), if known (e.g., 336212)
Number of Days Employment information
Total number of Total number of days of
days away from job transfer or restriction Annual average number of employees
work
Total hours worked by all employees last
year
(K) (L)
Injury and Illness Types Sign here
Total number of… Knowingly falsifying this document may result in a fine.
(M)
(1) Injury (4) Poisonings
(2) Skin Disorder (5) Hearing Loss
(3) Respiratory I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and
complete.
Conditions (6) All Other Illnesses
Company Executive Title
Post this Summary page from February 1 to April 30 of the year following the year covered by the form Phone Date
Public reporting burden for this collection of information is estimated to average 50 minutes per response, including time to review the instruction, search and gather the data
needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control
number. If you have any comments about these estimates or any aspects of this data collection, contact: Michigan Department of Licensing and Regulatory Affairs, MIOSHA,
TSD, 530 West Allegan Street, P.O. Box 30643, Lansing MI 48909-8143. (517) 284-7788. Do not send the completed forms to this office.
MIOSHA-300A (Rev. 12/16) Effective 01/01/2004