ATTACHMENT A

Bureau of Labor Statistics

Log and Summary of Occupational
Injuries and Illnesses Page _1__ of __1_ 09/10/19
NOTE: This form is required by Public Law 91-596 and must be kept in the RECORDABLE CASES: You are required to record information about every Company Name
establishment for 5 years. Failure to maintain and post occupational death, every nonfatal occupational illness, and those
nonfatal Form Approved
can result in the issuance of sitations and assessment of penalties. occupational injuries which involve one or more of the following: Loss of Establishment Name O.M.B. No. 1220-0029
(See posting requirements on the other side of ORIGINAL form.) consciousness, restriction of work or motion, transfer to another job, or
Directions are not included in this electronic copy. You must medical treatment (other than first aid). (See definitions on the other side Establishment Address See OMB Disclosure
see an ORIGINAL hard copy for the directions on the back. of form). Statement on Reverse
Case or Date of Employee's Name Occupation Department Description of Injury or Illness Extent of, and Outcome of INJURY Type, Extent of, and Outcome of ILLNESS
File Injury or
Number Onset of Fatalities Nonfatal Injuries Type of Illness Fatalities Nonfatal Illnesses
Illness
Injury Injuries With Lost Workdays Injuries CHECK only One Column for Each Illness Illness Illnesses With Lost Workdays Illnesses
Related Without Lost (See other side of form for terminations Related Without Lost
Enter a Enter Enter first name or initial Enter regular job title, not Enter department in which Enter a brief description of the injury or illness Workdays or permanent transfers). Workdays
nondupli- Mo./day middle initial, last name. activity employee was per- the employee is regularly and indicate the part or parts of body affected.
cating forming when injured or at employed or a description Enter DATE Enter a Enter a Enter num- Enter num- Enter a CHECK Occu P Enter DATE Enter a Enter a Enter num- Enter num- Enter a CHECK
number onset of illness. In the absence of normal workplace to of death CHECK CHECK if ber of ber of if no entry was patio o of death CHECK CHECK if ber of ber of if no entry was
which of a formal title, enter a brief which employee is assigned, if injury injury in- DAYS away DAYS of made in col- nal i if illness illness in- DAYS away DAYS of made in col-
will description of the employee's even though temporarily involves volves days from work. restricted umns 1 or 2 skin s involves volves days from work. restricted umns 1 or 2
facilitate duties. working in another depart- days away away from work activ- but the injury disea o days away away from work activ- but the illness
com- ment at the time of injury from work. ity. is recordable ses or n from work. ity. is recordable
parisons or illness. work or as defined disord i work or as defined
with days of above. ers n days of above.
supple- Typical entries for this column might be restricted g restricted
mentary Amputation of 1st joint right forefinger, Mo./day/yr. work Mo./day/yr. work
(
records Strain of lower back, Contact dermatitis activity activity
s
on both hands, Electrocution - body. or both. y or both.
(1) (2) (3) (4) (5) (6) s (7) (8) (9) (10) (11) (12) (13)
(A) (B) (C) (D) (E) (F) (a) (b) (c) t(d) (e) (f) (g)
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OSHA No. 200 U.S. GPO: 1990-262-256/15419 Fold Certification of Annual Summary Totals By ___________________________________________ Title _________________________________________Date ____________________
OSHA No. 200 POST ONLY THIS PORTION OF THE LAST PAGE NO LATER THAN FEBRUARY 1.

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