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OSHA Form 301 Checklist Template

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OSHA Form 301 Checklist Template

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

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