INJURY AND ILLNESS INCIDENT REPORT
ATTENTION:  This form contains information relating to employee health and must be used in a manner that protects the confidentiality of                   Michigan Department of Labor and Economic Opportunity
employees to the extent possible while the information is being used for occupational safety and health purposes.                                   Michigan Occupational Safety and Health Administration (MIOSHA)
                                                                                                                                                                                                                     Form Approved OMB No. 1218-0176
                                                          Information about the employee                                                     Information about the case
This Injury and Illness Incident Repor t is one of the 
first forms you must fill out when a recordable work-  1) Full Name                                                                      10) Case number from the Log        (Transfer the case number from the Log after you record the case.)
related injury or illness has occurred.  Together 
                                                       2) Street                                                                         11) Date of injury or illness
with the Log of Work-Related injuries  and 
Illnesses  and the accompanying Summary , these           City                 State                              Zip                    12) Time employee began work        AM/PM
forms help the employer and MIOSHA develop a 
picture of the extent and severity of work-related     3) Date of birth                                                                  13) Time of event                   AM/PM          Check if time cannot be determined
incidents.                                            
       Within 7 calendar days after you receive        4) Date hired                                                                     14) What was the employee doing just before the incident occurred?  Describe the activity, as well 
information that a recordable work-related injury or                                                                                         as the tools, equipment or material the employee was using.  Be specific.  Examples:  "climbing a 
illness has occurred, you must fill out this form or   5) Male          Female                                                               ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-
                                                                                                                                             entry."
an equivalent.  Some state workers' compensation, 
insurance, or other reports may be acceptable 
substitutes.  To be considered an equivalent form,        Information about the physician or other health care 
any substitute must contain all the information           professional
asked for on this form.                                                                                                                  15) What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, 
       According to Public Law of 1970 (P.L. 91-596)   6) Name of physician or other health care professional                                worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement"; 
and Michigan Occupational Safety and Health Act                                                                                              "Worker developed soreness in wrist over time."
154, P.A. 174, Part 11, Michigan Administrative 
Rule for Recording and Reporting Of Injuries and 
Illnesses, you must keep this form on file for 5       7) If treatment was given away from the worksite, where was it given?
years following the year to which it pertains. You 
may be fined for failure to comply.                       Facility                                                                       16) What was the injury or illness? Tell us the part of the body that was affected and how it was 
 If you need additional copies of this form, you may                                                                                         affected; be more specific than "hurt", "pain", or "sore." Examples: "strained back"; "chemical burn, 
photocopy and use as many as you need.                    Street                                                                             hand"; "carpal tunnel syndrome."
                                                          City                 State                              Zip
                                                       8) Was employee treated in an emergency room?
Completed by                                              Yes                                                                            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, leave it blank.
                                                          No
Title
                                                       9) Was employee hospitalized overnight as an in-patient?
Phone                   Date                              Yes

                                                          No                                                                             18) If the employee died, when did death occur?  Date of death

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 current valid OMB control number.  If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this 
burden, contact:  Michigan Department of Labor and Economic Opportunity, MIOSHA, TSD, 530 West Allegan Street, P.O. Box 30643, Lansing MI 48909-8143. (517) 284-7788. Do not send the completed forms to this office.
MIOSHA-301 (Rev. 03/20) Effective 01/01/2004