Header:
CALIFORNIA CODE OF REGULATIONS
TITLE 8. INDUSTRIAL RELATIONS
DIVISION 1. DEPARTMENT OF INDUSTRIAL RELATIONS
CHAPTER 7. DIVISION OF LABOR STATISTICS AND RESEARCH
SUBCHAPTER 1. OCCUPATIONAL INJURY OR ILLNESS REPORTS AND RECORDS
ARTICLE 2. EMPLO
Date:
08/31/2009
Document:
ยง 14300.48. Effective Date
The provisions of this article take effect on January 1, 2002 or on the effective date of the regulation, whichever is later.
Appendix A
Cal/OSHA Form 300 (Rev. 7/2007)
Log of Work-Related Injuries and Illnesses
[See Form In Original Printed Version]
Appendix B
Cal/OSHA Form 300A (Rev. 7/2007)
Annual Summary of Work-Related Injuries and Illnesses
[See Form In Original Printed Version]
Appendix C
Cal/OSHA Form 301
Injury and Illness Incident Report
[See Form In Original Printed Version]
Appendix D -- Required Elements for the Cal/OSHA 300 Equivalent Form
I. California employers who are required to record work-related injuries and illnesses on the Cal/OSHA Form 300 may use an equivalent form that includes all of the following instructions and information.
Log of Work-Related Injuries and Illnesses
Instruction: 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-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 8 CCR 14300.8 through 14300.12. Feel free to use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (Cal/OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you're not sure whether a case is recordable, contact the nearest office of the Division of Occupational Safety and Health for assistance.
Establishment Name & Address
Identify the Person (A)-(C)
A. Case Number
B. Employee's Name
C. Job Title
Describe the Case (D)-(F):
D. Date of Injury or illness
E. Where the event occurred
F. Describe the injury or illness, part(s) of the body affected, and object/substance that directly injured or made the person ill
Classify the Case (G)-(M)
Using these four categories (G)-(J), indicate only the most serious result for each case:
G. "Death"
H. "Days away from work"
I. Remained at work as "Other recordable cases"
J. Remained at work with "Job transfer or restriction"
Enter the number of days the injured or ill worker was:
K. Number of days the injured or ill worker was "Away from work"
L. Number of days the injured or ill worker was "On job transfer or restrictions"
M. Indicate an injury or, one type of illness:
(1) Injury column
(2) Skin disorder column
(3) Respiratory condition column
(4) Poisoning column
(5) Occupational hearing loss
(6) All other illnesses column
Page Totals (for columns (G)-(M))
Instruction: Transfer these totals to the Summary page (Cal/OSHA Form 300A) before you post it.
Instructions for privacy concerns:
"ATTENTION: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes."
Note: Privacy Concern Cases: employers using forms equivalent to the Cal/OSHA 300 are required to follow the privacy concern disclosure restrictions specified in Section 14300.29(b)(6)-(10).
Note: Additional Criteria. Beginning January 1, 2002, employers are required to record the following as specific injury and illness conditions. These are:
1. Injury from a needle or other sharp object that is contaminated with blood or OPIM (Reference: Section 14300.8)
2. Cases of medical removal under the requirements of a Cal/OSHA standard. (Reference: Section 14300.9)
3. Tuberculosis infection as evidenced by a positive skin test or diagnosis by a physician. (Reference: Section 14300.11)
Appendix E -- Required Elements for the Cal/OSHA Form 300A, Annual Summary of Work-Related Injuries and
Illnesses Equivalent Form.
A. Employers who are required to complete the Cal/OSHA Form 300A may use an equivalent form that provides all of the following information:
1. The number of cases:
(G) The total number of deaths
(H) The total number of cases with days away from work
(I) The total number of cases with job transfers or restriction
(J) The total number of other recordable cases
2. The number of days:
(K) The total number of days away from work
(L) The total number of days of job transfer or restriction
(M) Injury and Illness Types, the total numbers of:
1. Injuries
2. Skin disorders
3. Respiratory conditions
4. Poisonings
5. Hearing loss
6. All other illnesses
3. Posting requirement statement: "Post this Annual Summary from February 1 to April 30 of the year following the year covered by the form."
4. Establishment information:
. The establishment name
. Street address
. City, State, Zip
. Industry description
. The Standard Industry Classification Code, if known.
5. Employment information
. The annual average number of employees.
. The total hours worked by all employees last year.
(For assistance in calculating the annual average number of employees, and total hours worked, refer to Appendix G.)
6. Sign Here:
. Admonition: "Knowingly falsifying this statement may result in a fine."
. Certification statement: "I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete."
. Space for the signature of the company executive, and title.
. Phone number of signatory.
. Date of the certification.
Appendix F -- Required Elements for the Cal/OSHA 301 Injury and Illness Incident Report Equivalent Form
I. An employer that is required to fill out a Cal/OSHA Form 301 may use an equivalent form that provides the following items of information:
A. Information about the employee:
1. Full name
2. Home street address, city, state and Zip code
3. Date of birth
4. Date hired
5. Employee gender
B. Information about the physician or other health care professional:
6. Name of the physician or other health care professional who treated the employee
7. Name and complete address of the facility whre the employee received treatment (if applicable)
8. If the employee was treated in an emergency room (yes or no)
9. If the employee was hospitalized overnight as an in-patient (yes or no)
C. Information about the case:
10. The case number matching the Cal/OSHA log 300 (or equivalent) entry
11. The date of the injury or illness
12. Time of employee began work AM/PM
13. Time of the event AM/PM; or indication that the time cannot be determined
14. Description of what the employee was doing just before the incident occurred
15. Description of what happened; how the injury/illness occurred
16. The specific injury/illness, part(s) of the body affected, and medical diagnosis if available
17. Identify the object or substance that directly harmed the employee
18. If the employee died, the date of death
D. The name of the person the form was completed by
E. The title of the person who completed the form
F. The phone number of the person who completed the form
Appendix G
Worksheet to Help You Fill Out the Annual Summary
[See Form In Original Printed Version]
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