1 U.S. Department of Labor Occupational Safety and Health Administration OSHA Forms for Recording Work-Related Injuries and Illnesses Dear Employer: This booklet includes the forms needed for maintaining occupational injury and illness records for These new forms have changed in several important ways from the 2003 recordkeeping forms. In the December 17, 2002 Federal Register (67 FR ), OSHA announced its decision to add an occupational hearing loss column to OSHA s Form 300, Log of Work-Related Injuries and Illnesses. This forms package contains modified Forms 300 and 300A which incorporate the additional column M(5) Hearing Loss. Employers required to complete the injury and illness forms must begin to use these forms on January 1, In response to public suggestions, OSHA also has made several changes to the forms package to make the recordkeeping materials clearer and easier to use: On Form 300, we ve switched the positions of the day count columns. The days away from work column now comes before the days on job transfer or restriction. We ve clarified the formulas for calculating incidence rates. We ve added new recording criteria for occupational hearing loss to the Overview section. On Form 300, we ve made the column heading Classify the Case more prominent to make it clear that employers should mark only one selection among the four columns offered. The Occupational Safety and Health Administration shares with you the goal of preventing injuries and illnesses in our nation s workplaces. Accurate injury and illness records will help us achieve that goal. Occupational Safety and Health Administration U.S. Department of Labor What s Inside In this package, you ll find everything you need to complete OSHA s Log and the Summary of Work-Related Injuries and Illnesses for the next several years. On the following pages, you ll find: An Overview: Recording Work-Related Injuries and Illnesses General instructions for filling out the forms in this package and definitions of terms you should use when you classify your cases as injuries or illnesses. How to Fill Out the Log An example to guide you in filling out the Log properly. Log of Work-Related Injuries and Illnesses Several pages of the Log (but you may make as many copies of the Log as you need.) Notice that the Log is separate from the Summary. Summary of Work-Related Injuries and Illnesses Removable Summary pages for easy posting at the end of the year. Note that you post the Summary only, not the Log. Worksheet to Help You Fill Out the Summary A worksheet for figuring the average number of employees who worked for your establishment and the total number of hours worked. OSHA s 301: Injury and Illness Incident Report A copy of the OSHA 301 to provide details about the incident. You may make as many copies as you need or use an equivalent form. Take a few minutes to review this package. If you have any questions, visit us online at gov or call your local OSHA office. We ll be happy to help you.
2 U.S. Department of Labor Occupational Safety and Health Administration An Overview: Recording Work-Related Injuries and Illnesses The Occupational Safety and Health (OSH) Act of 1970 requires certain employers to prepare and maintain records of work-related injuries and illnesses. Use these definitions when you classify cases on the Log. OSHA s recordkeeping regulation (see 29 CFR Part 1904) provides more information about the definitions below. The Log of Work-Related Injuries and Illnesses (Form 300) 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. The Summary a separate form (Form 300A) shows the totals for the year in each category. At the end of the year, post the Summary in a visible location so that your employees are aware of the injuries and illnesses occurring in their workplace. Employers must keep a Log for each establishment or site. If you have more than one establishment, you must keep a separate Log and Summary for each physical location that is expected to be in operation for one year or longer. Note that your employees have the right to review your injury and illness records. For more information, see 29 Code of Federal Regulations Part , Employee Involvement. Cases listed on the Log of Work-Related Injuries and Illnesses are not necessarily eligible for workers compensation or other insurance benefits. Listing a case on the Log does not mean that the employer or worker was at fault or that an OSHA standard was violated. When is an injury or illness considered work-related? An injury or illness is considered work-related if an event or exposure in the work environment caused or contributed to the condition or significantly aggravated a preexisting condition. Work-relatedness is presumed for injuries and illnesses resulting from events or exposures occurring in the workplace, unless an exception specifically applies. See 29 CFR Part (b)(2) for the exceptions. The work environment includes the establishment and other locations where one or more employees are working or are present as a condition of their employment. See 29 CFR Part (b)(1). Which work-related injuries and illnesses should you record? Record those work-related injuries and illnesses that result in: death, loss of consciousness, days away from work, restricted work activity or job transfer, or medical treatment beyond first aid. You must also record work-related injuries and illnesses that are significant (as defined below) or meet any of the additional criteria listed below. You must record any significant workrelated injury or illness that is diagnosed by a physician or other licensed health care professional. You must record any work-related case involving cancer, chronic irreversible disease, a fractured or cracked bone, or a punctured eardrum. See 29 CFR What are the additional criteria? You must record the following conditions when they are work-related: any needlestick injury or cut from a sharp object that is contaminated with another person s blood or other potentially infectious material; any case requiring an employee to be medically removed under the requirements of an OSHA health standard; tuberculosis infection as evidenced by a positive skin test or diagnosis by a physician or other licensed health care professional after exposure to a known case of active tuberculosis. an employee's hearing test (audiogram) reveals 1) that the employee has experienced a Standard Threshold Shift (STS) in hearing in one or both ears (averaged at 2000, 3000, and 4000 Hz) and 2) the employee's total hearing level is 25 decibels (db) or more above audiometric zero ( also averaged at 2000, 3000, and 4000 Hz) in the same ear(s) as the STS. What is medical treatment? Medical treatment includes managing and caring for a patient for the purpose of combating disease or disorder. The following are not considered medical treatments and are NOT recordable: visits to a doctor or health care professional solely for observation or counseling; What do you need to do? 1. Within 7 calendar days after you receive information about a case, decide if the case is recordable under the OSHA recordkeeping requirements. 2. Determine whether the incident is a new case or a recurrence of an existing one. 3. Establish whether the case was workrelated. 4. If the case is recordable, decide which form you will fill out as the injury and illness incident report. You may use OSHA s 301: Injury and Illness Incident Report or an equivalent form. Some state workers compensation, insurance, or other reports may be acceptable substitutes, as long as they provide the same information as the OSHA 301. How to work with the Log 1. Identify the employee involved unless it is a privacy concern case as described below. 2. Identify when and where the case occurred. 3. Describe the case, as specifically as you can. 4. Classify the seriousness of the case by recording the most serious outcome associated with the case, with column G (Death) being the most serious and column J (Other recordable cases) being the least serious. 5. Identify whether the case is an injury or illness. If the case is an injury, check the injury category. If the case is an illness, check the appropriate illness category.
3 U.S. Department of Labor Occupational Safety and Health Administration diagnostic procedures, including administering prescription medications that are used solely for diagnostic purposes; and any procedure that can be labeled first aid. ( See below for more information about first aid. ) What is first aid? If the incident required only the following types of treatment, consider it first aid. Do NOT record the case if it involves only: using non-prescription medications at nonprescription strength; administering tetanus immunizations; cleaning, flushing, or soaking wounds on the skin surface; using wound coverings, such as bandages, BandAids, gauze pads, etc., or using SteriStrips or butterfly bandages. using hot or cold therapy; using any totally non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc.; using temporary immobilization devices while transporting an accident victim (splints, slings, neck collars, or back boards). drilling a fingernail or toenail to relieve pressure, or draining fluids from blisters; using eye patches; using simple irrigation or a cotton swab to remove foreign bodies not embedded in or adhered to the eye; using irrigation, tweezers, cotton swab or other simple means to remove splinters or foreign material from areas other than the eye; using finger guards; using massages; drinking fluids to relieve heat stress How do you decide if the case involved restricted work? Restricted work activity occurs when, as the result of a work-related injury or illness, an employer or health care professional keeps, or recommends keeping, an employee from doing the routine functions of his or her job or from working the full workday that the employee would have been scheduled to work before the injury or illness occurred. How do you count the number of days of restricted work activity or the number of days away from work? Count the number of calendar days the employee was on restricted work activity or was away from work as a result of the recordable injury or illness. Do not count the day on which the injury or illness occurred in this number. Begin counting days from the day after the incident occurs. If a single injury or illness involved both days away from work and days of restricted work activity, enter the total number of days for each. You may stop counting days of restricted work activity or days away from work once the total of either or the combination of both reaches 180 days. Under what circumstances should you NOT enter the employee s name on the OSHA Form 300? You must consider the following types of injuries or illnesses to be privacy concern cases: an injury or illness to an intimate body part or to the reproductive system, an injury or illness resulting from a sexual assault, a mental illness, a case of HIV infection, hepatitis, or tuberculosis, a needlestick injury or cut from a sharp object that is contaminated with blood or other potentially infectious material (see 29 CFR Part for definition), and other illnesses, if the employee independently and voluntarily requests that his or her name not be entered on the log. You must not enter the employee s name on the OSHA 300 Log for these cases. Instead, enter privacy case in the space normally used for the employee s name. You must keep a separate, confidential list of the case numbers and employee names for the establishment s privacy concern cases so that you can update the cases and provide information to the government if asked to do so. If you have a reasonable basis to believe that information describing the privacy concern case may be personally identifiable even though the employee s name has been omitted, you may use discretion in describing the injury or illness on both the OSHA 300 and 301 forms. You must enter enough information to identify the cause of the incident and the general severity of the injury or illness, but you do not need to include details of an intimate or private nature. What if the outcome changes after you record the case? If the outcome or extent of an injury or illness changes after you have recorded the case, simply draw a line through the original entry or, if you wish, delete or white-out the original entry. Then write the new entry where it belongs. Remember, you need to record the most serious outcome for each case. Classifying injuries An injury is any wound or damage to the body resulting from an event in the work environment. Examples: Cut, puncture, laceration, abrasion, fracture, bruise, contusion, chipped tooth, amputation, insect bite, electrocution, or a thermal, chemical, electrical, or radiation burn. Sprain and strain injuries to muscles, joints, and connective tissues are classified as injuries when they result from a slip, trip, fall or other similar accidents.
4 U.S. Department of Labor Occupational Safety and Health Administration Classifying illnesses Skin diseases or disorders Skin diseases or disorders are illnesses involving the worker s skin that are caused by work exposure to chemicals, plants, or other substances. Examples: Contact dermatitis, eczema, or rash caused by primary irritants and sensitizers or poisonous plants; oil acne; friction blisters, chrome ulcers; inflammation of the skin. Respiratory conditions Respiratory conditions are illnesses associated with breathing hazardous biological agents, chemicals, dust, gases, vapors, or fumes at work. Examples: Silicosis, asbestosis, pneumonitis, pharyngitis, rhinitis or acute congestion; farmer s lung, beryllium disease, tuberculosis, occupational asthma, reactive airways dysfunction syndrome (RADS), chronic obstructive pulmonary disease (COPD), hypersensitivity pneumonitis, toxic inhalation injury, such as metal fume fever, chronic obstructive bronchitis, and other pneumoconioses. Poisoning Poisoning includes disorders evidenced by abnormal concentrations of toxic substances in blood, other tissues, other bodily fluids, or the breath that are caused by the ingestion or absorption of toxic substances into the body. Examples: Poisoning by lead, mercury, cadmium, arsenic, or other metals; poisoning by carbon monoxide, hydrogen sulfide, or other gases; poisoning by benzene, benzol, carbon tetrachloride, or other organic solvents; poisoning by insecticide sprays, such as parathion or lead arsenate; poisoning by other chemicals, such as formaldehyde. Hearing Loss Noise-induced hearing loss is defined for recordkeeping purposes as a change in hearing threshold relative to the baseline audiogram of an average of 10 db or more in either ear at 2000, 3000 and 4000 hertz, and the employee s total hearing level is 25 decibels (db) or more above audiometric zero (also averaged at 2000, 3000, and 4000 hertz) in the same ear(s). All other illnesses All other occupational illnesses. Examples: Heatstroke, sunstroke, heat exhaustion, heat stress and other effects of environmental heat; freezing, frostbite, and other effects of exposure to low temperatures; decompression sickness; effects of ionizing radiation (isotopes, x-rays, radium); effects of nonionizing radiation (welding flash, ultra-violet rays, lasers); anthrax; bloodborne pathogenic diseases, such as AIDS, HIV, hepatitis B or hepatitis C; brucellosis; malignant or benign tumors; histoplasmosis; coccidioidomycosis. When must you post the Summary? You must post the Summary only not the Log by February 1 of the year following the year covered by the form and keep it posted until April 30 of that year. How long must you keep the Log and Summary on file? You must keep the Log and Summary for 5 years following the year to which they pertain. Do you have to send these forms to OSHA at the end of the year? No. You do not have to send the completed forms to OSHA unless specifically asked to do so. How can we help you? If you have a question about how to fill out the Log, visit us online at or call your local OSHA office.
5 Optional Calculating Injury and Illness Incidence Rates U.S. Department of Labor Occupational Safety and Health Administration What is an incidence rate? An incidence rate is the number of recordable injuries and illnesses occurring among a given number of full-time workers (usually 100 fulltime workers) over a given period of time (usually one year). To evaluate your firm s injury and illness experience over time or to compare your firm s experience with that of your industry as a whole, you need to compute your incidence rate. Because a specific number of workers and a specific period of time are involved, these rates can help you identify problems in your workplace and/or progress you may have made in preventing workrelated injuries and illnesses. How do you calculate an incidence rate? You can compute an occupational injury and illness incidence rate for all recordable cases or for cases that involved days away from work for your firm quickly and easily. The formula requires that you follow instructions in paragraph (a) below for the total recordable cases or those in paragraph (b) for cases that involved days away from work, and for both rates the instructions in paragraph (c). (a) To find out the total number of recordable injuries and illnesses that occurred during the year, count the number of line entries on your OSHA Form 300, or refer to the OSHA Form 300A and sum the entries for columns (G), (H), (I), and (J). (b) To find out the number of injuries and illnesses that involved days away from work, count the number of line entries on your OSHA Form 300 that received a check mark in column (H), or refer to the entry for column (H) on the OSHA Form 300A. (c) The number of hours all employees actually worked during the year. Refer to OSHA Form 300A and optional worksheet to calculate this number. You can compute the incidence rate for all recordable cases of injuries and illnesses using the following formula: Total number of injuries and illnesses X 200,000 Number of hours worked by all employees = Total recordable case rate (The 200,000 figure in the formula represents the number of hours 100 employees working 40 hours per week, 50 weeks per year would work, and provides the standard base for calculating incidence rates.) You can compute the incidence rate for recordable cases involving days away from work, days of restricted work activity or job transfer (DART) using the following formula: (Number of entries in column H + Number of entries in column I) X 200,000 Number of hours worked by all employees = DART incidence rate You can use the same formula to calculate incidence rates for other variables such as cases involving restricted work activity (column (I) on Form 300A), cases involving skin disorders (column (M-2) on Form 300A), etc. Just substitute the appropriate total for these cases, from Form 300A, into the formula in place of the total number of injuries and illnesses. What can I compare my incidence rate to? The Bureau of Labor Statistics (BLS) conducts a survey of occupational injuries and illnesses each year and publishes incidence rate data by various classifications (e.g., by industry, by employer size, etc.). You can obtain these published data at or by calling a BLS Regional Office. Worksheet Total number of injuries and illnesses Number of entries in Column H + Column I Number of hours worked by all employees X 200,000 = Number of hours worked by all employees X 200,000 = Total recordable case rate DART incidence rate
6 } Injury How to Fill Out the Log U.S. Department of Labor Occupational Safety and Health Administration The Log of Work-Related Injuries and Illnesses 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 company 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. We have given you several copies of the Log in this package. If you need more than we provided, you may photocopy and use as many as you need. The Summary a separate form 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. Then post the Summary in a visible location so that your employees are aware of injuries and illnesses occurring in their workplace. You don t post the Log. You post only the Summary at the end of the year. (Rev. 01/2004) R 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 29 CFR Part through Feel free to use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (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, call your local OSHA office for help. (A) (B) (C) (D) (E) (F) Describe injury or illness, parts of body affected, and object/substance that directly injured or made person ill Be as specific as possible. You can use two lines if you need more room. Revise the log if the injury or illness progresses and the outcome is more serious than you originally recorded for the case. Cross out, erase, or white-out the original entry. 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. CHECK ONLY ONE box for each case based on the most serious outcome for that case: Choose ONLY ONE of these categories. Classify the case by recording the most serious outcome of the case, with column G (Death) being the most serious and column J (Other recordable cases) being the least serious. Anywhere Enter the number of days the injured or ill worker was: Remained at Work Away On job from transfer or Job transfer Death Days away Other recordable cases from work or restriction work restriction (G) (H) (I) (J) (K) (L) Form approved OMB no XYZ Company Check the Injury column or choose one type of illness: (M) Skin disorders Respiratory conditions MA Poisoning Hearing loss (1) (2) (3) (4) (5) (6) Note whether the case involves an injury or an illness. All other illnesses
7 All other Illnesses Injury Injury All other Illnesses Cal/OSHA Form 300 (Rev. 7/2007) Appendix A Log of Work-Related Injuries and Illnesses 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. See CCR Title (b)(6)-(10) Year 20 Department of Industrial Relations Division of Occupational Safety and Health 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 CCR Title 8 Section through 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, call your local Cal/OSHA office for help. Establishment name City State Identify the person Describe the case Classify the case (A) (B) (C) (D) (E) (F) Using these four categories, check ONLY Enter the number of days the injured or Check the Injury column or Case Employee s name Job title Date of injury Where the event occurred Describe injury or illness, parts of body affected, the most serious result for each case: ill worker was: choose one type of illness: no. (e.g., Welder) or onset ( e.g., Loading dock north end) and object/substance that directly injured Days away (M) of illness or made person ill Death from work ( e.g., Second degree burns on right forearm from acetylene torch) Job transfer Other recordable or restriction cases (G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6) month/day days days days days month/day days days month/day days days month/day days days month/day days days month/day days days month/day month/day days days month/day days days month/day days days month/day days days month/day days days month/day days days Page totals Be sure to transfer these totals to the Summary page (Form 300A) before you post it. Page of Skin disorder Skin disorder Respiratory condition Respiratory condition P oisoning P oisoning Hearing losss Hearing loss (1) (2) (3) (4) (5) (6)
8 Cal/OSHA Form 300A (Rev. 7/2007) Appendix B Annual Summary of Work-Related Injuries and Illnesses Year 20 Department of Indus t rial Relations Division of Occupational Safety & Health All establishments covered by CCR Title 8 Section must complete this Annual Summary, even if no work-related 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. 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 every page of the Log. If you had no cases, write 0. Employees, former employees, and their representatives have the right to review the Cal/OSHA Form 300 in its entirety. They also have limited access to the Cal/OSHA Form 301 or its equivalent. See CCR Title 8 Section , in Cal/OSHA s recordkeeping rule, for further details on the access provisions for these forms. Number of Cases Total number of deaths Number of Days Total number of days away from work Total number of cases with days away from work Total number of cases with job transfer or restriction Total number of days of job transfer or restriction Total number of other recordable cases (G) (H) (I) (J) Establishment information Your establishment name Street City State ZIP Industry description ( e.g., Manufacture of motor truck trailers) Standard Industrial Classification (SIC), if known ( e.g., SIC 3715) Employment information Annual average number of employees Total hours worked by all employees last year (If you don t have these figures, use the optional Worksheet to estimate.) (K) (L) Sign here Knowingly falsifying this document may result in a fine. Injury and Illness Types Total number of... (M) (1) Injuries (2) Skin disorders (3) Respiratory conditions (4) Poisonings (5) Hearing loss (6)All other Illnesses I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete. Company executive Title Phone Dat e t Post this Annual Summary from February 1 t o April 30 of the year following the year covered by the form.
9 Optional Worksheet to Help You Fill Out the Summary At the end of the year, OSHA requires you to enter the average number of employees and the total hours worked by your employees on the summary. 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 the Summary page at the end of the year. How to figure the average number of employees who worked for your establishment during the year: Add the total number of employees your establishment paid in all pay periods during the year. Include all employees: full-time, part-time, temporary, seasonal, salaried, and hourly. Count the number of pay periods your establishment had during the year. Be sure to include any pay periods when you had no employees. The number of employees paid in all pay periods = The number of pay periods during the year = How to figure the total hours worked by all employees: Include 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, please estimate the hours that the employees actually worked. If this number isn t available, you can use this optional worksheet to estimate it. Optional Worksheet U.S. Department of Labor Occupational Safety and Health Administration Divide the number of employees by the number of pay periods. Round the answer to the next highest whole number. Write the rounded number in the blank marked Annual average number of employees. For example, Acme Construction figured its average employment this way: For pay period Acme paid this number of employees = The number rounded = Number of employees paid = 830 Number of pay periods = = rounds to is the annual average number of employees x + 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 in a 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.
10 Cal/OSHA Form 301 Appendix C Injury and Illness Incident Report 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. See CCR Title (b)(6)-(10) Department of Industrial Relations Division of Occupational Safety & Health This Injury and Illness Incident Report is one of the first forms you must fill out when a recordable workrelated injury or illness has occurred. Together with Log of Work-Related Injuries and Illnesses and the accompanying Annual Summary, these forms help the employer and Cal/OSHA develop a picture of the extent and severity of work-related incidents. Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out this form or an equivalent. Some state workers compensation, insurance, or other reports may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the instructions and information asked for on this form. According to CCR Title 8 Section Cal/OSHA s recordkeeping rule, you must keep this form on file for 5 years following the year to which it pertains. If you need additional copies of this form, you may photocopy and use as many as you need. Information about the employee 1) Full name 2) Street City State ZIP 3) Date of birth / / 4) Date hired / / 5) Male Female Information about the physician or other health care professional 6) Name of physician or other health care professional 7) If treatment was given away from the worksite, where was it given? Facility Information about the case 10) Case number from the Log 11) Date of injury or illness 13) Time of event (Transfer the case number from the Log after you record the case.) / / 12) Time employee began work AM / PM AM / PM Check if time cannot be determined 14) What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: climbing a ladder while carrying roofing materials ; spraying chlorine from hand sprayer ; daily computer key-entry. 15) What happened? Tell us how the injury occurred. Examples: When ladder slipped on wet floor, worker fell 20 feet ; Worker was sprayed with chlorine when gasket broke during replacement ; Worker developed soreness in wrist over time. 16) 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. Examples: strained back ; chemical burn, hand ; carpal tunnel syndrome. Street Completed by City State ZIP 8) Was employee treated in an emergency room? Ye s No 17) 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. Title Phone ( ) -- Date / / 9) Was employee hospitalized overnight as an in-patient? Ye s No 18) If the employee died, when did death occur? Date of death / /
11 If You Need Help If you need help deciding whether a case is recordable, or if you have questions about the information in this package, feel free to contact us. We ll gladly answer any questions you have. Visit us online at Call your OSHA Regional office and ask for the recordkeeping coordinator or Call your State Plan office Federal Jurisdiction State Plan States Oregon / Region / Alaska / Puerto Rico / Connecticut; Massachusetts; Maine; New Hampshire; Rhode Island Arizona / South Carolina / Region / California / Tennessee / New York; New Jersey *Connecticut / Utah / Region / DC; Delaware; Pennsylvania; West Virginia Hawaii / Vermont / U.S. Department of Labor Occupational Safety and Health Administration Region / Indiana / Virginia / Alabama; Florida; Georgia; Mississippi Iowa / Virgin Islands / Region / Illinois; Ohio; Wisconsin Kentucky / Washington / Region / Arkansas; Louisiana; Oklahoma; Texas Region / Kansas; Missouri; Nebraska Region / Colorado; Montana; North Dakota; South Dakota Region / Maryland / Wyoming / Michigan / Minnesota / Nevada / *New Jersey / New Mexico / *Public Sector only Region / Idaho *New York / North Carolina /
12 U.S. Department of Labor Occupational Safety and Health Administration Have questions? If you need help in filling out the Log or Summary, or if you have questions about whether a case is recordable, contact us. We ll be happy to help you. You can: Visit us online at: Call your regional or state plan office. You ll find the phone number listed inside this cover.
13 EMERGENCY AMBULANCE: FIRE RESCUE: HOSPITAL: PHYSICIAN: ALTERNATE: POLICE: CAL/OSHA: Posting is required by Title 8 Section 1512 (e), California Code of Regulations March 1990 S-500 State of California Department of Industrial Relations Cal/OSHA Publications P.O. Box San Francisco, CA
14 STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS Division of Workers' Compensation Notice to Employees--Injuries Caused By Work You may be entitled to workers' compensation benefits if you are injured or become ill because of your job. Workers' compensation covers most work-related physical or mental injuries and illnesses. An injury or illness can be caused by one event (such as hurting your back in a fall) or by repeated exposures (such as hurting your wrist from doing the same motion over and over). Benefits. Workers' compensation benefits include: Medical Care: Doctor visits, hospital services, physical therapy, lab tests, x-rays, and medicines that are reasonably necessary to treat your injury. You should never see a bill. There is a limit on some medical services. Temporary Disability (TD) Benefits: Payments if you lose wages while recovering. For most injuries, TD benefits may not be paid for more than 104 weeks within five years from the date of injury. Permanent Disability (PD) Benefits: Payments if your injury causes a permanent disability. Supplemental Job Displacement Benefit: A nontransferable voucher payable to a state approved school if your injury arises on or after 1/1/04 and results in a permanent disability that prevents you from returning to work within 60 days after TD ends, and your employer does not offer you modified or alternative work. Death Benefits: Paid to dependents of a worker who dies from a work-related injury or illness. Naming Your Own Physician Before Injury or Illness (Predesignation). You may be able to choose the doctor who will treat you for a job injury or illness. If eligible, you must tell your employer, in writing, the name and address of your personal physician or medical group before you are injured and your physician must agree to treat you for your work injury. For instructions, see the written information about workers' compensation that your employer is required to give to new employees. If You Get Hurt: 1. Get Medical Care. If you need emergency care, call 911 for help immediately from the hospital, ambulance, fire department or police department. If you need first aid, contact your employer. 2. Report Your Injury. Report the injury immediately to your supervisor or to an employer representative. Don't delay. There are time limits. If you wait too long, you may lose your right to benefits. Your employer is required to provide you a claim form within one working day after learning about your injury. Within one working day after you file a claim form, your employer shall authorize the provision of all treatment, consistent with the applicable treating guidelines, for your alleged injury and shall be liable for up to ten thousand dollars ($10,000) in treatment until the claim is accepted or rejected. 3. See Your Primary Treating Physician (PTP). This is the doctor with overall responsibility for treating your injury or illness. If you predesignated by naming your personal physician or medical group before injury (see above), you may see him or her for treatment in certain circumstances. Otherwise, your employer has the right to select the physician who will treat you for the first 30 days. You may be able to switch to a doctor of your choice after 30 days. Different rules apply if your employer offers a Health Care Organization (HCO) or has a Medical Provider Network (MPN). You should receive information from your employer if you are covered by an HCO or a MPN. Contact your employer for more information. 4. Medical Provider Networks. Your employer may be using a MPN, which is a selected network of health care providers to provide treatment to workers injured on the job. If your employer is using a MPN, a MPN notice should be posted next to this poster to explain how to use the MPN. You can request a copy of this notice by calling the MPN number below. If you have predesignated a personal physician prior to your work injury, then you may receive treatment from your predesignated doctor. If you have not predesignated and your employer is using a MPN, you are free to choose an appropriate provider from the MPN list after the first medical visit directed by your employer. If you are treating with a non-mpn doctor for an existing injury, you may be required to change to a doctor within the MPN. For more information, see the MPN contact information below: Current MPN s toll free number: MPN website: MPN Effective Date Current MPN s address: Discrimination. It is illegal for your employer to punish or fire you for having a work injury or illness, for filing a claim, or testifying in another person's workers' compensation case. If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state. Questions? Learn more about workers' compensation by reading the information that your employer is required to give you at time of hire. If you have questions, see your employer or the claims administrator (who handles workers' compensation claims for your employer): Claims Administrator Phone Workers compensation insurer (Enter self-insured if appropriate) Policy Expiration Date If the workers compensation policy has expired, contact a Labor Commissioner at the Division of Labor Standards Enforcement (DLSE). You can also get free information from a State Division of Workers' Compensation Information & Assistance Officer. The nearest Information & Assistance Officer can be found at location: or by calling toll-free (800) Learn more information about DWC and DLSE online: or False claims and false denials. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony and may be fined and imprisoned. Your employer may not be liable for the payment of workers' compensation benefits for any injury that arises from your voluntary participation in any off-duty, recreational, social, or athletic activity that is not part of your work-related duties. DWC 7 (6/10)
15 ESTADO DE CALIFORNIA - DEPARTAMENTO DE RELACIONES INDUSTRIALES División de Compensación de Trabajadores Aviso a los Empleados Lesiones Causadas por el Trabajo Es posible que usted tenga derecho a beneficios de compensación de trabajadores si usted se lesiona o se enferma a causa de su trabajo. La compensación de trabajadores cubre la mayoría de las lesiones y enfermedades físicas o mentales relacionadas con el trabajo. Una lesión o enfermedad puede ser causada por un evento (como por ejemplo el lastimarse la espalda en una caída) o por acciones repetidas (como por ejemplo lastimarse la muñeca por hacer el mismo movimiento una y otra vez). Beneficios. Los beneficios de compensación de trabajadores incluyen: Atención Médica: Consultas médicas, servicios de hospital, terapia física, análisis de laboratorio, radiografías y medicinas que son razonablemente necesarias para tratar su lesión. Usted nunca deberá ver un cobro. Hay un límite para ciertos servicios médicos. Beneficios por Incapacidad Temporal (TD): Pagos si usted pierde sueldo mientras se recupera. Para la mayoría de las lesiones, beneficios de TD no se pagarán por mas de 104 semanas dentro de cinco años después de la fecha de la lesión. Beneficios por Incapacidad Permanente (PD): Pagos si su lesión le causa una incapacidad permanente. Beneficio Suplementario por Desplazamiento de Trabajo: Un vale no-transferible pagadero a una escuela aprobada por el estado si su lesión surge en o después del 1/1/04, y le ocasiona una incapacidad permanente que le impida regresar al trabajo dentro de 60 días después de que los pagos por TD terminen y su empleador no le ofrece a usted un trabajo modificado o alternativo. Beneficios por Muerte: Pagados a los dependientes de un(a) trabajador(a) que muere a causa de una lesión o enfermedad relacionada con el trabajo. Designación de su Propio Médico Antes de una Lesión o Enfermedad (Designación previa). Es posible que usted pueda elegir al médico que le atenderá en una lesión o enfermedad relacionada con el trabajo. Si elegible, usted debe informarle al empleador, por escrito, el nombre y la dirección de su médico personal o grupo médico, antes de que usted se lesione y su médico debe estar de acuerdo de atenderle la lesión causada por el trabajo. Para instrucciones, vea la información escrita sobre la compensación de trabajadores que se le exige a su empleador darle a los empleados nuevos. Si Usted se Lastima: 1. Obtenga Atención Médica. Si usted necesita atención de emergencia, llame al 911 para ayuda inmediata de un hospital, una ambulancia, el departamento de bomberos o departamento de policía. Si usted necesita primeros auxilios, comuníquese con su empleador. 2. Reporte su Lesión. Reporte la lesión inmediatamente a su supervisor(a) o a un representante del empleador. No se demore. Hay límites de tiempo. Si usted espera demasiado, es posible que usted pierda su derecho a beneficios. Su empleador está obligado a proporcionarle un formulario de reclamo dentro de un día laboral después de saber de su lesión. Dentro de un día después de que usted presente un formulario de reclamo, el empleador autorizará todo tratamiento médico de acuerdo con las pautas de tratamiento aplicables a su presunta lesión y será responsable por diez mil dolares ($10,000) en tratamiento hasta que el reclamo sea aceptado o rechazado. 3. Consulte al Médico que le está Atendiendo (PTP). Este es el médico con la responsabilidad total de tratar su lesión o enfermedad. Si usted designó previamente a su médico personal o grupo médico antes lesionarse (vea uno de los párrafos anteriores), en ciertas circunstancias, usted puede consultarlo para el tratamiento. De otra forma, su empleador tiene el derecho de seleccionar al médico que le atenderá durante los primeros 30 días. Es posible que usted pueda cambiar a un médico de su preferencia después de 30 días. Hay reglas diferentes que se aplican cuando su empleador ofrece una Organización de Cuidado Médico (HCO) o si tiene una Red de Proveedores Médicos (MPN). Usted debe recibir información de su empleador si está cubierto por una HCO o una MPN. Hable con su empleador para más información. 4. Red de Proveedores Médicos (MPN): Es posible que su empleador use una MPN, lo cual es una red de proveedores de asistencia médica seleccionados para dar tratamiento a los trabajadores lesionados en el trabajo. Si su empleador usa una MPN, una notificación de la MPN debe estar al lado de este cartel para explicar como usar la MPN. Usted puede pedir una copia de esta notificación hablando al número de la MPN debajo descrito. Si usted ha hecho una designación previa de un médico personal antes de lesionarse en el trabajo, entonces usted puede recibir tratamiento de su medico previamente designado. Si usted no ha hecho una designación previa y su empleador está usando una MPN, usted puede escoger un proveedor apropiado de la lista de la MPN después de la primera visita médica dirigida por su empleador. Si usted está recibiendo tratamiento de parte de un médico que no pertenece a la MPN para una lesión existente, puede requerirse que usted se cambie a un médico dentro de la MPN. Para más información, vea la siguente información del contacto de la MPN : Número gratuito de la MPN vigente: Página web de la MPN: Fecha de vigencia de la MPN Dirección de la MPN vigente Discriminación. Es ilegal que su empleador le castigue o despida por sufrir una lesión o enfermedad en el trabajo, por presentar un reclamo o por testificar en el caso de compensación de trabajadores de otra persona. De ser probado, usted puede recibir pagos por pérdida de sueldos, reposición del trabajo, aumento de beneficios y gastos hasta los límites establecidos por el estado. Preguntas? Aprenda más sobre la compensación de trabajadores leyendo la información que se requiere que su empleador le dé cuando es contratado. Si usted tiene preguntas, vea a su empleador o al administrador de reclamos (que se encarga de los reclamos de compensación de trabajadores de su empleador): Administrador de Reclamos Teléfono Asegurador del Seguro de Compensación de trabajador (Anote autoasegurado si es apropiado) Fecha de Vencimiento de la Póliza Si la póliza de compensación de trabajadores se ha vencido, comuníquese con el Comisionado Laboral, en la División para el Cumplimiento de las Normas Laborales (Division of Labor Standards Enforcement- DLSE). Usted también puede obtener información gratuita de un Oficial de Información y Asistencia de la División Estatal de Compensación de Trabajadores. El Oficial de Información y Asistencia más cercano se localiza en o llamando al número gratuito (800) Usted puede obtener más información sobre de la DWC y DLSE en el Internet en: o Los reclamos falsos y rechazos falsos del reclamo. Cualquier persona que haga o que ocasione que se haga una declaración o una representación material intencionalmente falsa o fraudulenta, con el fin de obtener o negar beneficios o pagos de compensación de trabajadores, es culpable de un delito grave y puede ser multado y encarcelado. Es posible que su empleador no sea responsable por el pago de beneficios de compensación de trabajadores para ninguna lesión que proviene de su participación voluntaria en cualquier actividad fuera del trabajo, recreativa, social, o atlética que no sea parte de sus deberes laborales. DWC 7 (6/10)
16 State of California Department of Industrial Relations Division of Labor Standards Enforcement PAYDAY NOTICE REGULAR PAYDAYS FOR EMPLOYEES OF (FIRM NAME) SHALL BE AS FOLLOWS: THIS IS IN ACCORDANCE WITH SECTIONS 204, 204A, 204B, 205, AND OF THE CALIFORNIA LABOR CODE BY TITLE DLSE 8 (REV ) PLEASE POST
17 Division of Labor Standards Enforcement Office of the Labor Commissioner THIS POSTER MUST BE DISPLAYED WHERE EMPLOYEES CAN EASILY READ IT (Poster may be printed on 8 ½ x 11 letter size paper) HEALTHY WORKPLACES/HEALTHY FAMILIES ACT OF 2014 Entitlement: PAID SICK LEAVE An employee who, on or after July 1, 2015, works in California for 30 or more days within a year from the beginning of employment is entitled to paid sick leave. Paid sick leave accrues at the rate of one hour per every 30 hours worked, paid at the employee s regular wage rate. Accrual shall begin on the first day of employment or July 1, 2015, whichever is later. Accrued paid sick leave shall carry over to the following year of employment and may be capped at 48 hours or 6 days. However, subject to specified conditions, if an employer has a paid sick leave, paid leave or paid time off policy (PTO) that provides no less than 24 hours or three days of paid leave or paid time off, no accrual or carry over is required if the full amount of leave is received at the beginning of each year in accordance with the policy. Usage: An employee may use accrued paid sick days beginning on the 90 th day of employment. An employer shall provide paid sick days upon the oral or written request of an employee for themselves or a family member for the diagnosis, care or treatment of an existing health condition or preventive care, or specified purposes for an employee who is a victim of domestic violence, sexual assault, or stalking. An employer may limit the use of paid sick days to 24 hours or three days in each year of employment. Retaliation or discrimination against an employee who requests paid sick days or uses paid sick days or both is prohibited. An employee can file a complaint with the Labor Commissioner against an employer who retaliates or discriminates against the employee. For additional information you may contact your employer or the local office of the Labor Commissioner. Locate the office by looking at the list of offices on our website using the alphabetical listing of cities, locations, and communities. Staff is available in person and by telephone. DLSE Paid Sick Leave Posting 11/2014
18 Amends General Minimum Wage Order and IWC Industry and Occupation Orders Please Post Next to Your IWC Industry or Occupation Order OFFICIAL NOTICE California Minimum Wage MW-2014 Minimum Wage - Every employer shall pay to each employee wages not less than the following: $8.00 $9.00 $10.00 per hour beginning January 1, 2008 per hour beginning July 1, 2014 per hour beginning January 1, 2016 To employers and representatives of persons working in industries and occupations in the State of California: SUMMARY OF ACTIONS TAKE NOTICE that on September 25, 2013, the California Legislature enacted legislation signed by the Governor of California, raising the minimum wage for all industries. (AB10, Stats of 2013, amending section of the California Labor Code.) Pursuant to its authority under Labor Code section , the Department of Industrial Relations amends and republishes Sections 2, 3, and 5 of the General Minimum Wage Order, MW Section 1, Applicability, and Section 4, Separability, have not been changed. Consistent with this enactment, amendments are made to the minimum wage, and the meals and lodging credits sections of all of the IWC s industry and occupation orders. This summary must be made available to employees in accordance with the IWC s wage orders. Copies of the full text of the amended wage orders may be obtained by ordering on-line at or by contacting your local Division of Labor Standards Enforcement office. 1. APPLICABILITY The provisions of this Order shall not apply to outside salespersons and individuals who are the parent, spouse, or children of the employer previously contained in this Order and the IWC s industry and occupation orders. Exceptions and modifications provided by statute or in Section 1, Applicability, and in other sections of the IWC s industry and occupation orders may be used where any such provisions are enforceable and applicable to the employer. 2. MINIMUM WAGES Every employer shall pay to each employee wages not less than eight dollars ($8.00) per hour for all hours worked, effective January 1, 2008, not less than nine dollars ($9.00) per hour for all hours worked, effective July 1, 2014, and not less than ten dollars ($10.00) per hour for all hours worked, effective January 1, MEALS AND LODGING Meals or lodging may not be credited against the minimum wage without a voluntary written agreement between the employer and the employee. When credit for meals or lodging is used to meet part of the employer s minimum wage obligation, the amounts so credited may not be more than the following: Effective Effective Effective LODGING January 1, 2008 July 1, 2014 January 1, 2016 Room occupied alone... $37.63 per week $42.33 per week $47.03 per week Room shared.. $31.06 per week $34.94 per week $38.82 per week Apartment two thirds (2/3) of the ordinary rental value, and in no event more than: $ per month $ per month Where a couple are both employed by the employer, two thirds $ per month (2/3) of the ordinary rental value, and in no event more than:... $ per month $ per month $ per month MEALS Breakfast. $2.90 $3.26 $3.62 Lunch... $3.97 $4.47 $4.97 Dinner... $5.34 $6.01 $ SEPARABILITY If the application of any provision of this Order, or any section, subsection, subdivision, sentence, clause, phrase, word or portion of this Order should be held invalid, unconstitutional, unauthorized, or prohibited by statute, the remaining provisions thereof shall not be affected thereby, but shall continue to be given full force and effect as if the part so held invalid or unconstitutional had not been included herein. 5. AMENDED PROVISIONS This Order amends the minimum wage and meals and lodging credits in MW-2007, as well as in the IWC s industry and occupation orders. (See Orders 1-15, Secs. 4 and 10; and Order 16, Secs. 4 and 9.) This Order makes no other changes to the IWC s industry and occupation orders. These Amendments to the Wage Orders shall be in effect as of July 1, Questions about enforcement should be directed to the Division of Labor Standards Enforcement. Consult the white pages of your telephone directory under CALIFORNIA, State of, Industrial Relations for the address and telephone number of the office nearest you. The Division has offices in the following cities: Bakersfield, El Centro, Fresno, Long Beach, Los Angeles, Oakland, Redding, Sacramento, Salinas, San Bernardino, San Diego, San Francisco, San Jose, Santa Ana, Santa Barbara, Santa Rosa, Stockton, and Van Nuys.
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