New Form – Integrity Safety

301 - Form

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.

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 information asked for on this form.

According to Public Law 91-596 and 29 CFR 1904, 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 the printout or insert additional form pages in the PDF, and then use as many as you need.

Company ID

Company Contact

Employee ID

Completed by(Required)

Title(Required)

Phone(Required)

Date(Required)

Information about the employee

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

Date hired(Required)

Male

Female

Information about the physician or other health care professional

Name of physician or other health care professional(Required)

If treatment was given away from the worksite, where was it given?

Facility(Required)

Facility Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Was employee treated in an emergency room?(Required)

Yes

Was employee hospitalized overnight as an in-patient?(Required)

Yes

Information about the case

Case number from the Log(Required)

(Transfer the case number from the Log after you record the case.)

Date of injury or illness(Required)

Time employee began work(Required)

Time of event(Required)

Check if time cannot be determined

* Re fields 14 to 17: Please do not include any personally identifiable information (PII) pertaining to worker(s) involved in the incident (e.g., no names, phone numbers, or Social Security numbers).

* What was the employee doing just before the incident occurred?(Required)

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.

* What Happened? Tell us how the injury occurred.(Required)

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.”

* What was the injury or illness?(Required)

Tell us the part of the body that was affected and how it was affected. Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.”

* What object or substance directly harmed the employee?(Required)

Examples: “concrete floor”; “chlorine”; “radial arm saw.” If this question does not apply to the incident, leave it blank.

If the employee died, when did death occur?(Required)

Date of death