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                   Michigan Department of Licensing and Regulatory Affairs
of 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
                                                       1) Full Name                                                                   10) Case number from the Log        (Transfer the case number from the Log after you record the case.)
This Injury and Illness Incident Repor t is one of the 
first forms you must fill out when a recordable work-  2) Street                                                                      11) Date of injury or illness
related injury or illness has occurred.  Together with 
the Log of Work-Related injuries  and Illnesses  and      City                                   State               Zip              12) Time employee began work        AM/PM
the accompanying Summary , these forms help the 
employer and MIOSHA develop a picture of the           3) Date of birth                                                               13) Time of event                   AM/PM                                Check if time cannot be determined
extent and severity of work-related incidents.                                            
                                                       4) Date hired                                                                  14) What was the employee doing just before the incident occurred?  Describe the activity, as well 
       Within 7 calendar days after you receive                                                                                           as the tools, equipment or material the employee was using.  Be specific.  Examples:  "climbing a 
information that a recordable work-related injury or   5) Male                            Female                                          ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-
illness has occurred, you must fill out this form or                                                                                      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 Licensing and Regulatory Affairs, 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. 12/16) Effective 01/01/2004