Get the free Illness or Injury Report Form - workconnections umich

This form is used to report non-work related illnesses or injuries for contract workers not on U of M payroll. It is essential for MIOSHA reporting purposes and requires timely submission within 24

How to fill out illness or injury report

How to fill out Illness or Injury Report Form

1. Begin by filling in the date of the incident at the top of the form.
2. Provide your personal information, including your name, job title, and contact details.
3. Describe the nature of the illness or injury in detail, including any symptoms experienced.
4. State the date, time, and location where the incident occurred.
5. Document any witnesses present at the time of the incident.
6. Specify any medical treatment received, including the name of the healthcare provider.
7. Sign and date the form to certify that the information provided is accurate.

Who needs Illness or Injury Report Form?

1. Employees who have experienced an illness or injury at work.
2. Supervisors or managers needing to report accidents or incidents.
3. Human resources personnel for record-keeping and compliance purposes.
4. Insurance representatives for processing claims related to worker injuries.

People Also Ask about

Which 3 forms are used to record injuries and illnesses?

Establishments that meet certain size and industry criteria are required to electronically submit injury and illness data from their OSHA Form 300A, 300, and 301 (or equivalent forms) once per year to OSHA. OSHA collects this work-related injury and illness data through the Injury Tracking Application (ITA).

Is OSHA 301 form called the injury and illness incident report?

Occupational Safety and Health Administration (OSHA) Form 301, “Injury and Illness Incident Report,” is used by employers to keep a record of a single injury, illness, or death in a workplace. This form is found within OSHA Form 300, which is used to log and classify all such incidents for a workplace.

What are the 3 classifications of OSHA recordable injuries?

You must use OSHA 300, 300-A, and 301 forms, or equivalent forms, for recordable injuries and illnesses. The OSHA 300 form is called the Log of Work-Related Injuries and Illnesses, the 300-A is the Summary of Work-Related Injuries and Illnesses, and the OSHA 301 form is called the Injury and Illness Incident Report.

What is the injury and illness incident report?

Injury and Illness reporting is the reporting of workplace incidents that result in harm to an employee. It is often called incident reporting, though that is a broad term that can also include a range of incidents like vehicle accidents and chemical spills.

What are the three forms of OSHA?

You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you're not sure whether a case is recordable, call your local OSHA office for help. Be sure to transfer these totals to the Summary page (Form 300A) before you post it.

For pdfFiller’s FAQs

What is Illness or Injury Report Form?

It is a document used to report any illnesses or injuries that occur in the workplace, detailing the nature of the incident and its context.

Who is required to file Illness or Injury Report Form?

Typically, employees who experience an illness or injury at work are required to file this form, along with their supervisors or managers if it affects workplace safety.

How to fill out Illness or Injury Report Form?

To fill out the form, provide personal details, date and time of the incident, a description of the illness or injury, witnesses' information, and any actions taken after the incident.

What is the purpose of Illness or Injury Report Form?

The purpose is to document the incident for record-keeping, compliance, and to help prevent future occurrences by analyzing the circumstances around the incident.

What information must be reported on Illness or Injury Report Form?

The form must include details such as the employee's name, date and time of the incident, location, description of the illness or injury, witness names, and any immediate care provided.