Occupational Injury and Illness Reporting Program Please enter 0 if not applicable. Please use TAB key to move from space to space , NOT the return key. Quarter Ending:(Required) MM slash DD slash YYYY Company:(Required) Submitted By:(Required) First Last Phone:(Required)E-mail:(Required) FROM FORM No. 300: Recorded cases (including fatalities): Column G, H, I and J(Required) FROM FORM No. 300: Recordable cases without lost or restricted workdays (From Column J)(Required) FROM FORM No. 300: Lost workday cases (days away from work) From Column H:(Required) FROM FORM No. 300: Lost workdays: From Column K:(Required) FROM FORM No. 300: Restricted workdays: From Column L:(Required) FROM FORM No. 300: Number of specific recordable injuries/illnesses: From Column F:(Required) Number of Injuries/Illness by CATEGORY: HEAD(Required) Number of Injuries/Illness by CATEGORY: BACK(Required) Number of Injuries/Illness by CATEGORY: EYE(Required) Number of Injuries/Illness by CATEGORY: LEG(Required) Number of Injuries/Illness by CATEGORY: ARM(Required) Number of Injuries/Illness by CATEGORY: FOOT(Required) Number of Injuries/Illness by CATEGORY: HAND/FINGER(Required) Number of Injuries/Illness by CATEGORY: OTHER(Required) OTHER INFORMATION: Total Hours Worked by Employees through the Quarter:(Required) OTHER INFORMATION: Fatalities during the year: From Column G on Form 300:(Required) Δ
