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OSHA Form 300A — Summary

Complete your establishment info, review the auto-totals from your 300 Log, and print this summary for posting from February 1 through April 30 of the following year.

OSHA Form 300A

Summary of Work-Related Injuries and Illnesses

All establishments covered by 29 CFR Part 1904 must complete this Summary, even if no work-related injuries or illnesses occurred during the year.

Year: 1970

Establishment: YOUR COMPANY

City / State: ____________

Number of Cases

Deaths (G)0
Cases w/ days away from work (H)0
Cases w/ job transfer or restriction (I)0
Other recordable cases (J)0
Total recordable cases (G + H + I + J)0

Number of Days

Day away from work (K)0
Days of job transfer or restriction (L)0
Total (K + L)0

Injury and Illness Types

(1) Injuries (M1)0
(2) Skin disorders (M2)0
(3) Respiratory conditions (M3)0
(4) Poisonings (M4)0
(5) Hearing loss (M5)0
(6) All other illnesses (M6)0

Incident Rates (per 100 FTEs)

Total Case Rate (TCR) = (Total × 200,000) / Hours—
DART Rate = ((H + I) × 200,000) / Hours—
Total hours worked—
Avg employees—

Certification

I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete.

Name: ________________

Title: ________________

Phone: ________________

Date: ________________

Post this Summary from February 1 through April 30 of the year following the year covered by the form. 29 CFR Part 1904; OMB No. 1218-0176.