301 Log Form
Employee Information
Full name
Address
Date of birth
Date of hired
Gender
Information about the Physician or other Health Care Professional
Name of physician or other health care professional
Was treatment given away from the worksite?
Was the employee treated in an emergency room?
Was the employee hospitalized overnight as an in-patient?
Information about the Case
Case number from the log
Date of injury or illness
Time employee began work
Estimated time of the event (leave blank if time cannot be determined)
What was the employee doing before the incident occurred? Describe the activity, as well as the tools, equipment or material the employee was using.
What happened? Tell us how the injury occurred.
Type of incident
Describe the injury or illness? Tell us the part of the body that was affected and how it was affected
What object or substance directly harmed the employee?
Upload photos of the incident
Did the employee die?
Completion
Observations and comments
Full Name of Record Keeper
Signature of Record Keeper
