Enter name of Company or Agency
Enter the month to which this report relates
Enter total number of employees for the month
Insert total paid hours worked by all workers onsite excluding vacation, sickness, and short and long-term disability.
Enter number of deaths resulting from a workplace injury or illness, regardless of the time intervening between the incident and death.
Enter number of on-the-job illness or injuries suffered by employees that: 1. prevents the employee from returning to work on any day subsequent to the day on which the event occurred; or 2. results in loss of body member; or 3. resulted in permanent impairment of a body function
Please provide the date(s) and describe the injury(ies) and action(s) taken. Enter N/A if the answer to the preceding question is zero (0).
Enter total number of illness/injuries to employees that required medical treatment other than first aid.
Please provide the date(s) and describe the injury(ies) and action(s) taken. Enter N/A if the answer to the preceding question is zero (0).
Enter number of events that had the potential to cause death or serious injury to any person
Please provide the date(s) and describe the occurrence and action(s) taken. Enter N/A if the answer to the preceding question is zero (0).
Enter total days lost by all employees due to on the job injury/illness