Form Miosha-301 - Injury And Illness Incident Report

INJURY AND ILLNESS INCIDENT REPORT

Michigan Department of Labor and Economic Growth

Michigan Occupational Safety and Health Administration (MIOSHA)

ATTENTION: This form contains information relating to employee health and must be used in a manner that protects the

Form Approved OMB No. 1218-0176

confidentiality of employees to the extent possible while the information is being used for occupational safety and health

purposes.

Information about the employee

Information about the cases

This Injury and Illness Incident Report is one of the

1. FULL NAME

10. CASE NUMBER FROM THE LOG (Transfer the case number from the Log after you record the case.)

first forms you must fill out when a recordable work-

related injury or illness has occurred. Together with

2. STREET

11. DATE OF INJURY OR ILLNESS

the Log of Work-Related Injuries and Illnesses and

/

/

the accompanying Summary, these forms help the

CITY

STATE

ZIP CODE

12. TIME EMPLOYEE BEGAN WORK

employer and MIOSHA develop a picture of the extent

□ AM

□ PM

and severity of work-related incidents.

3. DATE OF BIRTH

13. TIME OF EVENT

Within 7 calendar days after you receive information

□ AM

□ PM

□ Check if time cannot be determined

/

/

that a recordable work-related injury or illness has

4. DATE HIRED

14. WHAT WAS THE EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED?

occurred, you must fill out this form or an equivalent.

Describe the activity as well as the tools, equipment, or material the employee was using. Be specific.

/

/

Some state workers’ compensation, insurance, or

Examples: “Climbing a ladder while carrying roofing materials”; “Spraying chlorine from hand sprayer”; “Daily

5.

computer key-entry.”

other reports may be acceptable substitutes. To be

□ MALE

□ FEMALE

considered an equivalent form, any substitute must

contain all the information asked for on this form.

According to Public law of 1970 (P.L. 91-596) and

15. WHAT HAPPENED?

Michigan Occupational Safety and Health Act 154,

Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was

Information about the physician or other health

P.A. 1974, Part 11, Michigan Administrative Rule for

sprayed with chlorine when gasket broke during replacement”; “Worker developed soreness in wrist over time.”

care professional

Recording and Reporting of Injuries and Illnesses, you

6. NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL

must keep this form on file for 5 years following the

year to which it pertains. You may be fined for failure

7. IF TREATMENT WAS GIVEN AWAY FROM THE WORKSITE, WHERE WAS IT GIVEN?

to comply.

If you need additional copies of this form, you may

16. WHAT WAS THE INJURY OR ILLNESS?

FACILITY

Tell us the part of the body that was affected and how it was affected; be more specific than “hurt,” “pain,”

photocopy and use as many as you need.

“sore.” Examples: “Strained Back”; “Chemical Burn on Hand”; “Carpal Tunnel Syndrome.”

STREET

CITY

STATE

ZIP CODE

COMPLETED BY

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,

8. WAS EMPLOYEE TREATED IN AN EMERGENCY ROOM?

leave it blank.

□ YES

TITLE

□ NO

9. WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS AN IN-PATIENT?

□ YES

18. IF THE EMPLOYEE DIED, WHEN DID DEATH OCCUR?

PHONE

DATE

□ NO

DATE OF DEATH

/

/

(

)

/

/

Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Persons are not required to respond to the collection of information unless it displays a currently valid OMB number. If you have any comments about these estimates or any other aspects of this data collection, including suggestions for reducing this burden, contact: Michigan

Department of Labor & Economic Growth, MIOSHA, MTSD, 7150 Harris Dr., P.O. Box 30643, Lansing MI 48909-8143 • (517) 322-1848 • Do not send completed forms to this office.

MIOSHA-301 (Rev. 12/03) Effective 01/01/2004