Appendix D - Required Elements for the Cal/OSHA 300 Equivalent Form

I. California employers who are required to record work-related injuries and illnesses on the Cal/OSHA Form 300 may use an equivalent form that includes all of the following instructions and information.

Log of Work-Related Injuries and Illnesses

Instruction: You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 8 CCR 14300.8 through 14300.12. Feel free to use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (Cal/OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you're not sure whether a case is recordable, contact the nearest office of the Division of Occupational Safety and Health for assistance.

Establishment Name & Address

Identify the Person (A)-(C)

A. Case Number

B. Employee's Name

C. Job Title

Describe the Case (D)-(F):

D. Date of Injury or illness

E. Where the event occurred

F. Describe the injury or illness, part(s) of the body affected, and object/substance that directly injured or made the person ill

Classify the Case (G)-(M)

Using these four categories (G)-(J), indicate only the most serious result for each case:

G. "Death"

H. "Days away from work"

I. Remained at work as "Other recordable cases"

J. Remained at work with "Job transfer or restriction"

Enter the number of days the injured or ill worker was:

K. Number of days the injured or ill worker was "On job transfer or restrictions"

L. Number of days the injured or ill worker was "Away from work"

M. Indicate an injury or, one type of illness:

(1) Injury column

(2) Skin disorder column

(3) Respiratory condition column

(4) Poisoning column

(5) All other illnesses column

Page Totals {for columns (G)-(M)}

Instruction: Transfer these totals to the Summary page (Cal/OSHA Form 300A) before you post it.

Instructions for privacy concerns:

"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."

Note: Privacy Concern Cases: employers using forms equivalent to the Cal/OSHA 300 are required to follow the privacy concern disclosure restrictions specified in Section 14300.29 (b)(6)-(10).

Note: Additional Criteria. Beginning January 1, 2002, employers are required to record the following as specific injury and illness conditions. These are:

1. Injury from a needle or other sharp object that is contaminated with blood or OPIM (Reference: Section 14300.8)

2. Cases of medical removal under the requirements of a Cal/OSHA standard. (Reference: Section 14300.9)

3. Tuberculosis infection as evidenced by a positive skin test or diagnosis by a physician. (Reference: Section 14300.11)

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