Year 20
LOG OF WORK-RELATED INJURIES AND ILLNESSES Michigan Department of Licensing and Regulatory Affairs
ATTENTION: This form contains information relating to employee health and must be used in a manner that protects the Michigan Occupational Safety and Health Administration (MIOSHA)
confidentiality of employees to the extent possible while the information is being used for occupational safety and health
purposes. Form Approved OMB No. 1218-0176
You must record information about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first ESTABLISHMENT NAME
aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses
that meet any of the specific recording criteria listed in Public Law of 1970 (P.L. 91-596) and Michigan Occupational Safety and Health Act 154, P.A. 1974, Part 11, Michigan Administrative Rule for
Recording and Reporting of Injuries and Illnesses. Feel free to use two lines for a single case if you need to. You must complete an injury and illness incident report (MIOSHA 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 MIOSHA office for help. You may be fined for failure to comply. CITY STATE
IDENTIFY THE PERSON DESCRIBE THE CASE CLASSIFY THE CASE
Using these four categories, check ONLY the one most Check the "injury" column or
(A) (B) (C) (D) (E) (F) serious result for each case: Enter the number of choose one type of illness:
days the injured or ill
Case Employee's Name Job Title (e.g., Date of injury or Where the event occurred Describe injury or illness, parts of body worker was:
No. Welder) onset of illness (e.g. Loading dock north affected, and object/substance that
end) directly injured or made person ill (e.g. (M)
(month/day) Second degree burns on right forearm Days Away On job
from acetylene torch) Death away Remained at work transfer or
from From restriction
Job transfer or Other recordable cases Work (days)
(days)
restriction Injury Skin Disorder Respiratory Condition Poisoning Hearing Loss All other illnesses
(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6)
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Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review the instruction, Page totals
search and gather the data needed, and complete and review 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 these estimates or any aspects of this Be sure to transfer these totals to the Summary page (Form 300A) before you post it.
data collection, contact: Injury
Michigan Department of Licensing and Regulatory Affairs, MIOSHA, TSD, Condition Poisoning
530 West Allegan Street, P.O. Box 30643, Lansing MI 48909-8143. (517) 284-7788 Hearing Standard Threshold Shifts must Respiratory
Do not send the completed forms to this office. Skin Disorder Hearing Loss
be recorded under Column 5 All other illnesses
MIOSHA-300 (rev. 12/16) Effective 01/01/2004
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