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
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/
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.
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/
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
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/
(
)
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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