Appendix E - Required Elements for the Cal/OSHA Form 300A,
Annual Summary of Work-Related Injuries and Illnesses Equivalent Form

A. Employers who are required to complete the Cal/OSHA Form 300A may use an equivalent form that provides all of the following information:

1. The number of cases:

(G) The total number of deaths

(H) The total number of cases with days away from work

(I) The total number of cases with job transfers or restriction

(J) The total number of other recordable cases

2. The number of days:

(K) The total number of days of job transfer or restriction

(L) The total number of days away from work

(M) Injury and Illness Types, the total numbers of:

1. Injuries

2. Skin disorders

3. Respiratory conditions

4. Poisonings

5. All other illnesses

3. Posting requirement statement: "Post this Annual Summary from February 1 to April 30 of the year following the year covered by the form."

4. Establishment information:

The establishment name

Street address

City, State, Zip

Industry description

The Standard Industry Classification Code, if known.

5. Employment information

The annual average number of employees.

The total hours worked by all employees last year.

(For assistance in calculating the annual average number of employees, and total hours worked, refer to Appendix G.)

6. Sign Here:

Admonition: "Knowingly falsifying this statement may result in a fine."

Certification statement: "I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete."

Space for the signature of the company executive, and title.

Phone number of signatory.

Date of the certification.

NOTE: Authority cited: Section 6410, Labor Code. Reference: Section 6410, Labor Code.