Appendix F - Required Elements for the Cal/OSHA 301 Injury and Illness Incident Report Equivalent Form

I. An employer that is required to fill out a Cal/OSHA Form 301 may use an equivalent form that provides the following items of information:

A. Information about the employee:

1. Full name

2. Home street address, city, state and Zip code

3. Date of birth

4. Date hired

5. Employee gender

B. Information about the physician or other health care professional:

6. Name of the physician or other health care professional who treated the employee

7. Name and complete address of the facility where the employee received treatment (if applicable)

8. If the employee was treated in an emergency room (yes or no)

9. If the employee was hospitalized overnight as an in-patient (yes or no)

C. Information about the case:

10. The case number matching the Cal/OSHA Log 300 (or equivalent) entry

11. The date of the injury or illness

12. Time of employee began work AM/PM

13. Time of the event AM/PM; or indication that the time cannot be determined

14. Description of what the employee was doing just before the incident occurred

15. Description of what happened; how the injury/illness occurred

16. The specific injury/illness, part(s) of the body affected, and medical diagnosis if available

17. Identify the object or substance that directly harmed the employee

18. If the employee died, the date of death

D. The name of the person the form was completed by

E. The title of the person who completed the form

F. The phone number of the person who completed the form

G. Privacy concern instruction:

"ATTENTION: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes." Reference: Section 14300.29 (b)(6)-(10)

H. The instruction "Within 7 days of receiving information that a recordable work-related injury or illness has occurred, you must fill out this form or the Cal/OSHA Form 301."

II. Note: When a work-connected fatality or serious injury occurs, every employer is required to report the incident immediately (within 8 hours) by telephone or in person to the nearest District Office of the Division of Occupational Safety and Health. Reference: General Industry Safety Orders Section 342 Reporting Work-Connected Fatalities and Serious Injuries.

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