DoL OSHA 3165-04R 2019-2026 free printable template
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Job Safety and Health
U.S. Department of Labor It's THE LAW! All workers have the right to:Employers must: A safe workplace. Provide employees a workplace free from
recognized hazards. It is illegal
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How to fill out DoL OSHA 3165-04R
01
Obtain the DoL OSHA 3165-04R form from the OSHA website or your employer.
02
Begin by filling out the employer information section, including the name, address, and contact details.
03
Provide the employee's personal information such as name, job title, and department.
04
Complete the incident details section, including the date, time, and location of the incident.
05
Describe the nature of the incident, including the type of injury or illness sustained.
06
Include any witness statements or information in the designated section of the form.
07
Review the form for accuracy and completeness before submission.
08
Submit the completed form to your employer or the designated OSHA representative.
Who needs DoL OSHA 3165-04R?
01
Employers required to report workplace injuries or illnesses.
02
Employees who experience a work-related injury that needs to be documented.
03
Occupational safety professionals and compliance officers.
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What is DoL OSHA 3165-04R?
DoL OSHA 3165-04R is a form used by employers to report occupational injuries and illnesses to the Occupational Safety and Health Administration (OSHA).
Who is required to file DoL OSHA 3165-04R?
All employers who are covered by the Occupational Safety and Health Act and have incurred workplace injuries or illnesses are required to file DoL OSHA 3165-04R.
How to fill out DoL OSHA 3165-04R?
To fill out DoL OSHA 3165-04R, the employer must provide information regarding the injured employee, the nature of the incident, and details about the injury or illness, following the instructions outlined on the form.
What is the purpose of DoL OSHA 3165-04R?
The purpose of DoL OSHA 3165-04R is to collect information about work-related injuries and illnesses to improve workplace safety and monitor compliance with OSHA regulations.
What information must be reported on DoL OSHA 3165-04R?
The information that must be reported includes the employee's personal details, the type of injury or illness, the date and time of the incident, the location, and any medical treatment provided.
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