Survey of Occupational Injuries and Illnesses,:
Tell us about the Case
Go to your completed OSHA Form 300. Copy the case information from that form into the spaces below.
Job title ________
Date of injury or onset of illness ___/___/___
Number of days away from work_____
Number of days of job transfer or restriction_____
Tell us about the Employee
Check the category which best describes the employee's regular type of job or work: (optional)
- Office, professional, business, or management staff
- Product assembly, manufacture
- Repair, installation or service of machines, equipment
- Other (specify)
- Delivery or driving
- Food service
- Cleaning, maintenance of building, grounds
- Material handling (e.g. stocking, loading/unloading, moving, etc.)
Employee’s race or ethnic background: (optional-check one or more)
- American Indian or Alaska Native
- Black or African American
- Hispanic or Latino
- Native Hawaiian or Other Pacific Islander
- Not available
NOTE: You may either answer questions (3) to (13) or attach a copy of a supplementary document that answers them.
Employee’s age: ___OR date of birth: Month___Day___Year___
Employee’s date hired: Month___Day___Year___
OR check length of service at establishment when incident occurred:
- Less than 3 months
- From 3 to 11 months
- From 1 to 5 years
- Someone in household died from food allergy (Go to M1died, then skip to Section P)
- More than 5 years
Tell us about the incident
Answer the questions below or attach a copy of a supplementary document that answers them.
Was employee treated in an emergency room?
Was employee hospitalized overnight as an in-patient?
Time employee began work_____
Time of event_____
- pm OR
- Check if time cannot be determined
What was the employee doing just before the incident occurred? Describe the activity as well as the tools, equipment, or material the employee was using. Be specific. Examples: “climbing a ladder while carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.”
What happened? Tell us how the injury or illness occurred.
Examples: “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker developed soreness in wrist over time.”
What was the injury or illness? Tell us the part of the body that
was affected and how it was affected; be more specific than “hurt,”
“pain,” or “sore.” Examples: “strained back”; “chemical burn,
hand”; “carpal tunnel syndrome.”
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.