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301 Injuries and Illnesses Incident Report

This Injury and Illness Incident Report is one of the first forms you must fill out when a recordable work-related injury or illness has occurred. Together with the Log of Work-Related injuries and Illnesses and the accompanying Summary, these forms help the employer and OSHA develop a picture of the extent and severity of work-related incidents.

  • Info about Employee

  • Info about the Case

  • MM slash DD slash YYYY
  • :
  • MM slash DD slash YYYY
  • :

  • Employer's Information

  • Info about Physician/Other Health Care Prof.

  • Case Info Continued

  • 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."
  • 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."
  • Tell us the part of the body that was affected and how it was affected. Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."
  • Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank.
  • MM slash DD slash YYYY
    Date of death

  • Treatment

  • Other

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Completed by:

  • MM slash DD slash YYYY
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