[{"id":"8dc13013-661c-4b41-8638-c8bceb9ff3be","order":1,"text":"WORKPLACE INJURY AND INCIDENT REPORT","fontSize":"20","textAlign":"center","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"56051c80-24bc-46cd-829f-8b0950ba63b0","order":2,"text":"Employer's Record of a Work-Related Injury, Illness or Incident, Investigation and Corrective Action","fontSize":"16","textAlign":"center","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"fdeff99c-171b-4690-b549-655dcd655c1b","order":3,"text":"Completed as an equivalent form to the Injury and Illness Incident Report (OSHA Form 301) under 29 C.F.R. § 1904.29(b)(4)","fontSize":"12","textAlign":"center","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"01fbcfc9-36d8-4186-b1f1-78326f51ad71","order":4,"text":"CONFIDENTIAL — CONTAINS INFORMATION RELATING TO EMPLOYEE HEALTH","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"90a28bdb-0842-4984-a9b9-0b1efc1dc6b3","order":5,"text":"This report contains information relating to the health of an identified individual. It must be used in a manner that protects the confidentiality of that individual to the extent possible while the information is being used for occupational safety and health purposes, and it is kept in a confidential medical file separate from personnel records.","fontSize":"12","textAlign":"left","bold":false,"underline":false,"marginBottom":"15","cflou":false,"active":true},{"id":"207c3c56-055f-41d6-8d2f-4e3e2e82c584","order":6,"text":"Status of this report: This report is prepared and maintained in the ordinary course of business, as part of the occupational safety and health program of the organization named below.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"15","cflou":false,"active":true},{"id":"37b86236-7830-4168-a24d-358b533de3b4","order":7,"text":"Report reference: [Internal report reference] — Date of this report: [Date of this report]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"cd2a0ea0-fecf-4a36-a334-37ba87aee311","order":8,"text":"Case number on the Log of Work-Related Injuries and Illnesses (OSHA Form 300), where the case is recordable: [Case number, once assigned]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"69154f69-97d7-406c-b4b7-e53f08d6c9f9","order":9,"text":"Completed by: [Full name], [Job title], telephone [Telephone number].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"9094b6f9-a0cf-42cf-9e9a-1769400cae9b","order":10,"text":"1. EMPLOYER AND ESTABLISHMENT INFORMATION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S01"},{"id":"e4386cc0-1de4-4a63-9994-1b48bf9f8ab5","order":11,"text":"The employer responsible for this report (the "Employer") is [Legal name of the employer], trading as [Trade name or d/b/a], whose principal place of business is at [Street address], [City, State and ZIP code].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"896d0e0c-82af-4500-8095-b60b457eb3b8","order":12,"text":"The establishment at which the incident occurred (the "Establishment") is [Establishment or site name], located at [Street address of the establishment], [City, State and ZIP code].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"25dc7b87-c026-4b0c-b775-7b5a514eae82","order":13,"text":"The Establishment is classified under North American Industry Classification System code [NAICS code]. The Employer Identification Number used by the Establishment is [Employer Identification Number].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"45a6f59b-0d4a-4086-888d-762208a4beb0","order":14,"text":"A separate Log of Work-Related Injuries and Illnesses is kept for the Establishment in accordance with 29 C.F.R. § 1904.30, and any case recorded under this report is entered on that Log. Where the Employer is partially exempt from keeping those records by reason of size or industry classification, this report is nevertheless completed as a record of the incident and of the Employer's investigation, and the obligation to report severe events to OSHA is unaffected by any such exemption.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"80523b3f-5e03-4309-ab92-fc7491dc5ece","order":15,"text":"2. THE INJURED OR AFFECTED PERSON","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S02"},{"id":"5070edc9-2170-4278-9a34-259f2264b707","order":16,"text":"The person who sustained the injury or illness recorded in this report (the "Injured Person") is [Full name], whose home address is [Home street address], [City, State and ZIP code], telephone [Telephone number].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"5737318d-db5f-46d2-969c-7c7aa9153c80","order":17,"text":"The Injured Person was born on [Date of birth]. The gender recorded for the purposes of the Injury and Illness Incident Report is not stated.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"53e36a26-f03a-47b3-a292-00817a5dcf15","order":18,"text":"The date on which the Injured Person was hired is [Date hired].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"41f20d83-2c20-4d6a-b250-71341b34883f","order":19,"text":"At the time of the incident the Injured Person held the position of [Job title] in the [Department or work unit], and reported to [Name of the immediate supervisor], [Title of the immediate supervisor].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"394eca36-2343-41ec-be99-ff357611e923","order":20,"text":"The Injured Person was present at the Establishment in the following capacity: [Capacity in which the person was present]. The visit concerned the [Department or work unit concerned], and the person within the Establishment responsible for the visit was [Name of the person responsible], [Title of that person].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"add","operator":"="}]},{"id":"b75e003e-bbce-4204-be09-673ab1cfa05c","order":21,"text":"At the time of the incident the Injured Person was an employee on the Employer's payroll.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"ec522094-e696-4292-8af2-f686829f187c","order":22,"text":"A person present in the work environment as a member of the general public rather than as an employee falls within the exception at 29 C.F.R. § 1904.5(b)(2)(i), and a case falling within that exception is not recordable on the Employer's Log. The determination recorded under the heading WORK-RELATEDNESS, RECORDABILITY AND ENTRY ON THE OSHA FORMS governs. This report is completed in full in any event, as a record of the incident, of the investigation carried out and of the corrective action taken.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"add","operator":"="}]},{"id":"4b072adf-5272-4587-a550-c2d3b2151163","order":23,"text":"3. ALLOCATION OF RECORDING RESPONSIBILITY BETWEEN EMPLOYERS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"an employee on the Employer's payroll","type":"remove","operator":"="},{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}],"sectionNum":"S03"},{"id":"b99b9442-d383-4686-a1ca-93fcf4a06275","order":24,"text":"The Injured Person is employed or supplied by [Legal name of the staffing agency, contractor or subcontractor], of [Street address, city, State and ZIP code] (the "Other Employer"). The contact for the Other Employer is [Name and title of the contact], telephone [Telephone number].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"an employee on the Employer's payroll","type":"remove","operator":"="},{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"b8a73a8b-b99a-4dec-84f1-2adb0fd05041","order":25,"text":"Day-to-day supervision of the work of the Injured Person at the Establishment was provided by the Employer.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"an employee on the Employer's payroll","type":"remove","operator":"="},{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"c8d67258-5302-4e18-bc6b-9fb429c9fdcf","order":26,"text":"Under 29 C.F.R. § 1904.31, an employer records on its own Log the recordable injuries and illnesses of all employees on its payroll and of any other worker whom it supervises on a day-to-day basis. The Employer and the Other Employer shall coordinate their records so that this case is recorded once only, on the Log of the employer identified above as providing day-to-day supervision, and neither shall assume that the other has recorded it.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"an employee on the Employer's payroll","type":"remove","operator":"="},{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"56051c9f-4497-49df-bdc2-5cdbf7e9e53f","order":27,"text":"A copy of this report, with any information whose disclosure is restricted by law removed, has been or shall be transmitted to the Other Employer for the purposes of its own recordkeeping, claims administration and corrective action. Each employer remains separately responsible for the safety of the persons under its control and for its own compliance with the Occupational Safety and Health Act.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"an employee on the Employer's payroll","type":"remove","operator":"="},{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"03a41dbe-b912-47bb-ba3d-facf78e6a726","order":28,"text":"4. TIME, PLACE AND CIRCUMSTANCES OF THE INCIDENT","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S04"},{"id":"d8a07cf1-7698-4c75-b7bc-12f5bc9a3e6b","order":29,"text":"The injury or illness occurred on [Date of the injury or illness]. The Injured Person began work, or arrived at the Establishment, on that day at [Time work began or the person arrived], and the event occurred at approximately [Time of the event].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"bb8e160e-eb1c-4d4b-bf05-476f37b18d0a","order":30,"text":"The event occurred at [Specific location within or outside the establishment], in [City and State in which the event occurred].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"3a64ac54-314a-4155-af7b-b2efdb6b89f6","order":31,"text":"At the time of the event the Injured Person was on the Employer's premises and engaged in the performance of assigned duties.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"3e6905aa-02b7-41c4-845d-8af77cd995bb","order":32,"text":"The incident was first reported to the Employer on [Date on which the incident was reported] at [Time at which the incident was reported], to [Name and title of the person to whom it was reported].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"538a69f0-31c8-4da1-b1b3-7fcf57ce3f49","order":33,"text":"The Employer has established a reasonable procedure for the prompt and accurate reporting of work-related injuries and illnesses, as required by 29 C.F.R. § 1904.35(b)(1)(i), and that procedure has been made known to the workforce of the Establishment. No requirement of that procedure operated in this case so as to deter or discourage the making of a report, and no delay in reporting has been treated as a ground for disciplinary action.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"853467d9-5ee2-4363-8d45-38ae387d58fd","order":34,"text":"5. NARRATIVE ACCOUNT OF THE INCIDENT","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S05"},{"id":"2e681616-d74a-4af5-a29a-c18d445af5a3","order":35,"text":"The following account is recorded as soon as practicable after the incident, while the facts remain fresh, and is stated factually and without conclusion as to fault.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"01cb87db-b905-4763-8481-abc8c0bffacc","order":36,"text":"What the Injured Person was doing just before the incident occurred, including the tools, equipment or materials then in use:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"5278d757-b930-4639-b142-d99a891c2f7e","order":37,"text":"[Describe the activity and the tools, equipment or materials in use]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"15","cflou":false,"active":true},{"id":"a9e429a7-9b7a-4690-8602-0433fd0dda6a","order":38,"text":"What happened, and how the injury or illness occurred:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"30a6d542-84ea-46e6-8a3d-ddd95834c027","order":39,"text":"[Describe the sequence of events]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"15","cflou":false,"active":true},{"id":"c4e82ce3-1492-4a8a-8d3b-b08f17d2a2c5","order":40,"text":"The injury or illness sustained, the part or parts of the body affected and any medical diagnosis available:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"6ea22e47-e80c-47bc-b029-05a42c7243ba","order":41,"text":"[Describe the injury or illness]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"15","cflou":false,"active":true},{"id":"831a47a5-921d-4eba-b586-53eee2597f54","order":42,"text":"The object or substance which directly harmed the Injured Person:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"7185f63a-05c1-4914-9c9c-cec29503cb2f","order":43,"text":"[Identify the object or substance]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"15","cflou":false,"active":true},{"id":"2d4ebc2e-76d1-4014-b610-53209e3d2bfe","order":44,"text":"The equipment, tool, machine, vehicle or substance involved in the incident, with its identification or asset number:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"23f3aaff-a0ce-4288-ac49-561db0f1c084","order":45,"text":"[Identify the item and its asset or serial number]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"15","cflou":false,"active":true},{"id":"cdc1ed82-d610-4653-b3fb-8ede307fdc0c","order":46,"text":"The personal protective equipment in use by the Injured Person at the moment of the incident was as follows: [Identify the protective equipment worn or in use, or state that none was worn and whether any was required].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"f31531ef-a920-495d-b025-18b32d96c128","order":47,"text":"The Injured Person last received instruction or training on the task being performed on [Date of the last training on the task], and the experience of the Injured Person in that task is [Length of experience in the task].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"3a3e98cf-3b21-42ca-be57-169eec983252","order":48,"text":"6. NATURE OF THE INJURY OR ILLNESS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S06"},{"id":"f143fa1c-9c86-4687-856d-08669b6f34ee","order":49,"text":"For the purposes of the Log of Work-Related Injuries and Illnesses, the case is classified as an injury.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"0a9dddab-914c-494f-85ac-7d51473e5817","order":50,"text":"The nature of the injury or illness is [Nature of the injury or illness] and the part or parts of the body affected are [Part or parts of the body affected].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"b731690d-4c0d-447a-9eac-a8bf6889dc50","order":51,"text":"The Injured Person did not lose consciousness as a result of the incident, and the case is a new case within the meaning of 29 C.F.R. § 1904.6.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"66ec67c4-9d8e-4cd1-a142-b2e41ce53544","order":52,"text":"Those two entries govern the determination recorded below. A work-related loss of consciousness makes a case recordable of itself, however brief the loss and whatever the treatment given, so that a case recorded above as involving a loss of consciousness cannot be classified as requiring no more than first aid. Conversely, only a new case is recorded: where the entry above records a recurrence of a condition already entered on the Log which had not completely recovered, no fresh entry is made and the existing entry is updated instead.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"b1fa5e76-ac97-4129-a62f-9e7c42240829","order":53,"text":"7. MEDICAL TREATMENT AND CARE","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S07"},{"id":"a0733b3d-1cb5-4f21-9832-68acb26faa6a","order":54,"text":"The Injured Person was attended by [Name of the physician or other licensed health care professional] at [Name of the facility], [Street address of the facility], [City, State and ZIP code].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"ab6db399-296a-483c-837f-87beae95e398","order":55,"text":"Treatment was given on [Date of treatment] and consisted of the following: [Describe the treatment given]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"ae12d897-3526-44a0-836c-0233dd04eda4","order":56,"text":"The Injured Person was not treated in an emergency room, and was not hospitalized overnight as an in-patient.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"febc2155-5e59-4c65-828c-9f5d6724ac7b","order":57,"text":"For the purposes of 29 C.F.R. Part 1904, first aid means only the treatments listed at 29 C.F.R. § 1904.7(b)(5)(ii). That list is exhaustive. Any management or care of the patient falling outside it is medical treatment beyond first aid, irrespective of the professional status of the person who provided it; and treatment falling within it remains first aid even where it is provided by a physician. Visits made solely for observation or counseling, and diagnostic procedures such as radiographs and blood tests, are not medical treatment. It follows that where this report records a formal admission to the in-patient service of a hospital or clinic for care or treatment, or any other management falling outside that list, the case cannot be classified as one requiring no more than first aid.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"8e6d7fbf-d3bc-47ab-96fd-3a7f3fd7c004","order":58,"text":"Any record of the medical condition of the Injured Person obtained by the Employer is kept in a confidential medical file separate from personnel records and is disclosed only to those who require it for occupational safety and health, claims administration or legal purposes, or as otherwise required by law.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"5de9de76-d761-486b-9d43-2f1892efaf0e","order":59,"text":"8. WORK-RELATEDNESS, RECORDABILITY AND ENTRY ON THE OSHA FORMS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S08"},{"id":"c97e7193-8a00-4393-a7eb-4bcdccd2a052","order":60,"text":"An injury or illness is work-related if an event or exposure in the work environment either caused or contributed to the resulting condition, or significantly aggravated a pre-existing injury or illness. Work-relatedness is presumed for injuries and illnesses resulting from events or exposures occurring in the work environment, unless one of the exceptions listed at 29 C.F.R. § 1904.5(b)(2) applies. The work environment comprises the establishment and any other location where an employee is working or is present as a condition of employment, together with the equipment and materials used in the course of that work.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"ccf7e34b-17ce-4968-8230-a9ad88efad56","order":61,"text":"A work-related injury or illness which is a new case must be recorded if it results in death, days away from work, restricted work or transfer to another job, medical treatment beyond first aid, or loss of consciousness, or if it involves a significant injury or illness diagnosed by a physician or other licensed health care professional. Work-related cases involving cancer, chronic irreversible disease, a fractured or cracked bone or a punctured eardrum are recorded at the time of diagnosis in every case.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"a7b4112c-adb9-4870-aee3-1cbab27ac315","order":62,"text":"Having applied those criteria to the facts recorded above, the Employer determines that the case is work-related and recordable as a case in which the Injured Person received medical treatment beyond first aid, lost consciousness, or sustained a significant injury or illness diagnosed by a physician or other licensed health care professional, without days away from work, restricted work or transfer to another job.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"0a434802-2f16-4e92-b8b6-82f8f70340d0","order":63,"text":"The exception relied upon is that at the time of the injury or illness, the Injured Person was present in the work environment as a member of the general public rather than as an employee.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is not work-related, an exception listed at 29 C.F.R. § 1904.5(b)(2) being applicable, and is therefore not recordable","type":"add","operator":"="}]},{"id":"eacb9a8d-fd12-4256-bfac-7e46daefa682","order":64,"text":"The exception relied upon must be consistent with the capacity in which the Injured Person was present, as recorded above. In particular, the exception for a person present as a member of the general public is not open where the Injured Person was an employee of the Employer, or a worker whose work the Employer supervised on a day-to-day basis; and the exception for a mental illness is not open where an opinion of a physician or other licensed health care professional stating that the illness is work-related has been voluntarily provided. Where the two entries cannot be reconciled, the determination is revisited before this report is finalized.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is not work-related, an exception listed at 29 C.F.R. § 1904.5(b)(2) being applicable, and is therefore not recordable","type":"add","operator":"="}]},{"id":"656f3f98-a6ba-4985-a26a-feaac94dc378","order":65,"text":"The case being recordable, the Employer shall enter it on the Log of Work-Related Injuries and Illnesses (OSHA Form 300) and shall complete an Injury and Illness Incident Report (OSHA Form 301) or an equivalent form, within seven (7) calendar days of receiving information that a recordable injury or illness has occurred. This report is intended to serve as that equivalent form. Only one case-classification column is marked on the Log, being the column which corresponds to the most serious outcome of the case.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is not work-related, an exception listed at 29 C.F.R. § 1904.5(b)(2) being applicable, and is therefore not recordable","type":"remove","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related but required no more than first aid as defined at 29 C.F.R. § 1904.7(b)(5)(ii), and is therefore not recordable","type":"remove","operator":"="}]},{"id":"0fb0be43-8db9-4749-9705-f1d4a31af773","order":66,"text":"The case not being recordable, no entry is made on the Log of Work-Related Injuries and Illnesses. This report is retained as a record of the incident, of the Employer's investigation, of the corrective action taken and of the basis on which the case was found not to be recordable.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is not work-related, an exception listed at 29 C.F.R. § 1904.5(b)(2) being applicable, and is therefore not recordable","type":"add","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related but required no more than first aid as defined at 29 C.F.R. § 1904.7(b)(5)(ii), and is therefore not recordable","type":"add","operator":"="}]},{"id":"7e00f068-53c2-454e-883c-25a87bb7696d","order":67,"text":"The Injured Person was away from work for [Number of calendar days away from work] calendar days, the period of absence having begun on [First day away from work] and the Injured Person having returned, or being expected to return, on [Date of return to work].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a case involving days away from work","type":"add","operator":"="}]},{"id":"9031d655-e486-41e9-96ae-f0aaf031dc24","order":68,"text":"Days away from work are counted from the day after the injury occurred or the illness began. Weekend days, holidays, vacation days and other days off are included where the Injured Person would have been unable to work on those days. Where the count is not yet known it is estimated and later updated, and where it exceeds 180 calendar days the figure of 180 is entered on the Log. Where a physician or other licensed health care professional recommends that the Injured Person remain away from work, those days are counted even if the Injured Person is willing to work; and where the Injured Person leaves the Employer for a reason unrelated to the injury or illness, the count stops on the date of departure.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a case involving days away from work","type":"add","operator":"="}]},{"id":"009e4140-dc0a-463f-b318-cc26f13a3e59","order":69,"text":"The Injured Person performed restricted work, or was transferred to another job, for [Number of calendar days of restricted work or job transfer] calendar days, beginning on [Date on which the restriction began]. The restrictions or the transfer are as follows: [Describe the restrictions imposed or the job to which the person was transferred]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a case involving restricted work or transfer to another job","type":"add","operator":"="}]},{"id":"63b7bbc0-5307-41bd-84ac-318662bcee42","order":70,"text":"Restricted work arises where the Injured Person is kept from performing one or more of the routine functions of the job, or from working the full workday which would otherwise have been worked, whether by the decision of the Employer or on the recommendation of a physician or other licensed health care professional. Routine functions are the work activities performed at least once per week. A restriction or transfer imposed only for the day on which the injury occurred or the illness began is not recorded, and at least one day is counted where the restriction is recorded. The count is capped at 180 calendar days, and stops where the Injured Person leaves the Employer for a reason unrelated to the injury or illness. A recommendation of restriction made by a physician or other licensed health care professional is followed for the purposes of the count.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a case involving restricted work or transfer to another job","type":"add","operator":"="}]},{"id":"c0082181-77cd-4fc3-8ee1-53f9a5cb8f16","order":71,"text":"The Injured Person died on [Date of death]. The next of kin was notified on [Date of notification], the person notified being [Name and relationship of the person notified].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"add","operator":"="}]},{"id":"31c797ea-8fc2-49ff-90fe-f2e778451948","order":72,"text":"The following injuries and illnesses are privacy concern cases: an injury or illness to an intimate body part or to the reproductive system; an injury or illness resulting from a sexual assault; a mental illness; an infection with human immunodeficiency virus, hepatitis or tuberculosis; a needlestick injury or cut from a sharp object contaminated with another person's blood or other potentially infectious material; and any other illness where the employee voluntarily asks that the name not be entered on the Log. That list is exhaustive.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is not work-related, an exception listed at 29 C.F.R. § 1904.5(b)(2) being applicable, and is therefore not recordable","type":"remove","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related but required no more than first aid as defined at 29 C.F.R. § 1904.7(b)(5)(ii), and is therefore not recordable","type":"remove","operator":"="}]},{"id":"475293c0-863f-4b91-87e0-eb4d24a60e72","order":73,"text":"The Employer determines that this case is not a privacy concern case within the meaning of 29 C.F.R. § 1904.29(b)(7).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is not work-related, an exception listed at 29 C.F.R. § 1904.5(b)(2) being applicable, and is therefore not recordable","type":"remove","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related but required no more than first aid as defined at 29 C.F.R. § 1904.7(b)(5)(ii), and is therefore not recordable","type":"remove","operator":"="}]},{"id":"17a31237-41be-4d18-bb56-f8460d3b9236","order":74,"text":"The name of the Injured Person is accordingly not entered on the Log; the entry "privacy case" is made in the space normally used for the name, and the case number and the name are entered on a separate confidential list maintained for that purpose. Where the Employer has a reasonable basis to believe that the description of the case may itself identify the Injured Person, the description entered on the Log and on the Injury and Illness Incident Report is limited to what is needed to identify the cause of the incident and the general severity of the injury or illness.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4f075600-1ed3-4748-96d0-e8f6c1e24ad5","value":"is a privacy concern case within the meaning of 29 C.F.R. § 1904.29(b)(7)","type":"add","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is not work-related, an exception listed at 29 C.F.R. § 1904.5(b)(2) being applicable, and is therefore not recordable","type":"remove","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related but required no more than first aid as defined at 29 C.F.R. § 1904.7(b)(5)(ii), and is therefore not recordable","type":"remove","operator":"="}]},{"id":"3aeaffe1-fda0-481a-afb1-8a1a62fe1d39","order":75,"text":"The name of the Injured Person is accordingly entered on the Log in the ordinary way.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4f075600-1ed3-4748-96d0-e8f6c1e24ad5","value":"is not a privacy concern case within the meaning of 29 C.F.R. § 1904.29(b)(7)","type":"add","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is not work-related, an exception listed at 29 C.F.R. § 1904.5(b)(2) being applicable, and is therefore not recordable","type":"remove","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related but required no more than first aid as defined at 29 C.F.R. § 1904.7(b)(5)(ii), and is therefore not recordable","type":"remove","operator":"="}]},{"id":"395c71b9-ec7a-4897-852e-829577dc41e2","order":76,"text":"This determination is made by [Full name], [Job title], on [Date of the determination]. It shall be revisited, and the Log amended, if further information is received which changes the classification or the outcome of the case.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"e34cf344-1d13-44d4-925a-a6d93b15f211","order":77,"text":"The recording or reporting of a work-related injury, illness or fatality does not mean that the Employer or the Injured Person was at fault, that an occupational safety and health rule has been violated, or that the Injured Person is entitled to workers' compensation or to any other benefit.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"a80c24fb-899f-4764-ad2e-1fab2529237b","order":78,"text":"9. ADDITIONAL RECORDING CRITERIA FOR SPECIFIC CASES","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S09"},{"id":"9885f3ab-9f7e-4a74-aca4-17c2dd823e6c","order":79,"text":"In addition to the general recording criteria, 29 C.F.R. §§ 1904.8 to 1904.12 lay down criteria for five categories of case. Those criteria apply in addition to the general criteria, and a case which meets one of them is recordable even where the general criteria are not met.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"31d1e427-79e9-40ae-b58c-b2a0c406716f","order":80,"text":"Needlestick and sharps injuries. A work-related needlestick injury, or a cut from a sharp object contaminated with another person's blood or other potentially infectious material as defined in the bloodborne pathogens standard, is recorded as an injury and is treated as a privacy concern case, so that the name of the Injured Person is not entered on the Log. Where a case first recorded as an injury is later followed by the diagnosis of a bloodborne illness, the entry is updated and the classification changed from an injury to an illness.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"406187c4-8521-4b40-b342-da49b8aefd6b","order":81,"text":"Medical removal. Where a person is medically removed under the medical surveillance requirements of an OSHA standard, the case is recorded on the Log as a case involving either days away from work or restricted work, according to the manner in which the Employer complies with the removal requirement. Where the removal results from a chemical exposure, the poisoning column is checked. Voluntary removal below the level at which a standard requires removal is not recorded under this criterion.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"cdc287f5-4b4e-4b81-af93-8aa881146249","order":82,"text":"Occupational hearing loss. A case is recorded where an audiogram reveals a work-related Standard Threshold Shift in one or both ears and the total hearing level in the same ear or ears is 25 decibels or more above audiometric zero, averaged at 2000, 3000 and 4000 hertz. A Standard Threshold Shift is a change in hearing threshold, relative to the baseline audiogram for that person, averaging 10 decibels or more at those three frequencies in one or both ears. The current audiogram may be age-adjusted when determining whether a Standard Threshold Shift has occurred, but not when determining whether the total hearing level reaches 25 decibels above audiometric zero. Where a retest carried out within thirty (30) days does not confirm the shift, the case is not recorded; where it confirms the shift, the case is recorded within seven (7) calendar days of the retest, and the hearing loss column is checked.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"79dabe3d-3786-4bb0-8f8c-b405c98f6894","order":83,"text":"Tuberculosis. Where a person occupationally exposed to a known case of active tuberculosis subsequently develops a tuberculosis infection, evidenced by a positive skin test or by diagnosis by a physician or other licensed health care professional, the case is recorded and the respiratory condition column is checked. A positive skin test obtained at a pre-employment examination is not recorded, no occupational exposure to a known case having occurred.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"e5f05090-6c11-47c0-938e-5036448bf4f8","order":84,"text":"Musculoskeletal disorders. A work-related musculoskeletal disorder is recorded where it meets the general recording criteria applicable to every other case; no separate or additional criterion applies to it, and it is not marked as a distinct category on the Log.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"8d91d38b-2b6f-4601-9cc3-293c28b7977f","order":85,"text":"10. REPORTING OF FATALITIES AND SEVERE INJURIES TO OSHA","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S10"},{"id":"9070b79f-d5cf-4363-9541-ff2b3aa3d795","order":86,"text":"Every employer covered by the Occupational Safety and Health Act must report to OSHA the death of an employee resulting from a work-related incident within eight (8) hours, and the in-patient hospitalization of one or more employees, an amputation or the loss of an eye resulting from a work-related incident within twenty-four (24) hours. Those obligations apply to every covered employer, including an employer which is partially exempt from keeping injury and illness records.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"1a0007b8-2675-4190-9513-0983a2cf3046","order":87,"text":"A fatality is reportable only where death occurs within thirty (30) days of the work-related incident; an in-patient hospitalization, amputation or loss of an eye is reportable only where it occurs within twenty-four (24) hours of the work-related incident. In-patient hospitalization means a formal admission to the in-patient service of a hospital or clinic for care or treatment, and does not include admission solely for observation or diagnostic testing. An amputation is the traumatic loss of a limb or other external body part, including a fingertip amputation with or without bone loss, but does not include an avulsion, an enucleation, a degloving, a scalping, a severed ear or a broken or chipped tooth.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"305510e9-f00e-4e97-a591-d3c97ab3a878","order":88,"text":"Where the event is not learned of at the time it takes place, the period runs from the moment at which the event, or its work-related character, is reported to the Employer or to any agent of the Employer. The report is made by telephone or in person to the OSHA Area Office nearest to the site of the incident, by telephone to the toll-free number 1-800-321-OSHA (1-800-321-6742), or by electronic submission using the reporting application on the OSHA public website. Where the Area Office is closed, only the toll-free number or the electronic application may be used.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"aca1afe8-911a-4d41-bf37-a0e58864e704","order":89,"text":"In this case, no event requiring notification to OSHA under 29 C.F.R. § 1904.39 has occurred.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"94630bfe-8ea6-4fe0-850b-cecb0c63a338","order":90,"text":"No fatality, in-patient hospitalization, amputation or loss of an eye has resulted from this incident, and no notification under 29 C.F.R. § 1904.39 is therefore required. Should any such consequence arise within the periods stated above, the Employer shall make the report within the applicable time limit.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"089ae786-7081-444c-a2f8-3a9fdbaa3c74","value":"no event requiring notification to OSHA under 29 C.F.R. § 1904.39 has occurred","type":"add","operator":"="}]},{"id":"426a9708-eeaa-4a30-b399-2212ae0f6793","order":91,"text":"The report was made to OSHA on [Date of the report to OSHA] at [Time of the report] by [Name and title of the person who made the report], by telephone to the OSHA toll-free number.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"089ae786-7081-444c-a2f8-3a9fdbaa3c74","value":"no event requiring notification to OSHA under 29 C.F.R. § 1904.39 has occurred","type":"remove","operator":"="}]},{"id":"4b42bad0-0b45-4bcf-a39d-c54ac79caeac","order":92,"text":"The information given to OSHA comprised the name of the Establishment, the location and time of the work-related incident, the type of reportable event, the number and the names of the employees affected, the name and telephone number of the Employer's contact person, and a brief description of the incident. The Employer shall preserve the scene so far as is consistent with the safety of persons and shall cooperate with any inspection which follows.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"089ae786-7081-444c-a2f8-3a9fdbaa3c74","value":"no event requiring notification to OSHA under 29 C.F.R. § 1904.39 has occurred","type":"remove","operator":"="}]},{"id":"eb724779-aaf2-43ce-aafe-8e8c7e585511","order":93,"text":"This report records a work-related fatality but records no notification to OSHA. The obligation to report is independent of the obligation to record: the death of an employee resulting from a work-related incident and occurring within thirty (30) days of that incident must be reported within eight (8) hours, whether or not the case is entered on the Log and whether or not the Employer is partially exempt from keeping records. Before this report is finalized, the Employer shall establish whether that report has been made and, if it has not, make it without delay and complete this section accordingly.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"add","operator":"="},{"field":"089ae786-7081-444c-a2f8-3a9fdbaa3c74","value":"a work-related fatality has occurred and must be reported to OSHA within eight (8) hours","type":"remove","operator":"="},{"field":"089ae786-7081-444c-a2f8-3a9fdbaa3c74","value":"a work-related in-patient hospitalization, amputation or loss of an eye has occurred and must be reported to OSHA within twenty-four (24) hours","type":"remove","operator":"="}]},{"id":"03e20581-443d-492d-98e7-f23c357a05e1","order":94,"text":"This report records a reportable event while concluding that the case is not recordable. The two determinations are made under different provisions and do not always coincide, an event being reportable under 29 C.F.R. § 1904.39 irrespective of any recordkeeping exemption. They are nevertheless difficult to reconcile here: a death, an in-patient hospitalization, an amputation or the loss of an eye resulting from a work-related incident will ordinarily involve medical treatment beyond first aid, and a case which is not work-related at all is not reportable under that section. The Employer shall review both determinations before this report is finalized.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is not work-related, an exception listed at 29 C.F.R. § 1904.5(b)(2) being applicable, and is therefore not recordable","type":"add","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related but required no more than first aid as defined at 29 C.F.R. § 1904.7(b)(5)(ii), and is therefore not recordable","type":"add","operator":"="},{"field":"089ae786-7081-444c-a2f8-3a9fdbaa3c74","value":"no event requiring notification to OSHA under 29 C.F.R. § 1904.39 has occurred","type":"remove","operator":"="}]},{"id":"13e55bea-827f-4e20-b2bc-2756d30a3234","order":95,"text":"The duty to notify under 29 C.F.R. § 1904.39 is owed in respect of employees, which for this purpose includes any worker whose work the Employer supervises on a day-to-day basis. An event affecting a person present as a member of the general public is not reportable under that section, and the entry recorded above is to be read accordingly. This is without prejudice to any duty to notify arising under another Federal or State provision, under the plan of a State which operates its own occupational safety and health program, or under the law governing the premises, and the Employer shall satisfy itself which of those applies.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"add","operator":"="},{"field":"089ae786-7081-444c-a2f8-3a9fdbaa3c74","value":"no event requiring notification to OSHA under 29 C.F.R. § 1904.39 has occurred","type":"remove","operator":"="}]},{"id":"6dafad17-fe20-461f-a3a0-6a51b36f1552","order":96,"text":"11. WITNESSES AND WITNESS STATEMENTS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S11"},{"id":"ed96573c-5103-4f9e-b331-db23a78dd29d","order":97,"text":"The Employer has identified the following number of witnesses to the incident, or to the circumstances immediately preceding or following it: none.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"6d474f4e-966c-4d7b-abb6-e18d144cc203","order":98,"text":"No person other than the Injured Person is known to have witnessed the incident, or no witness has been identified at the date of this report. Should a witness be identified later, a statement shall be taken and appended to this report.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"0ebfe4ee-a7c4-4854-894b-057039ca26a6","value":"none","type":"add","operator":"="}]},{"id":"404c2d01-0f83-4896-8fea-c108fe79b1ff","order":99,"text":"Each statement below was taken as soon as practicable after the incident and separately from the other witnesses, and records the recollection of the witness in the words of the witness. No witness has been asked to adopt the account of any other person.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"0ebfe4ee-a7c4-4854-894b-057039ca26a6","value":"none","type":"remove","operator":"="}]},{"id":"004848b9-b16b-4c1d-9dda-b9f99ebf124d","order":100,"text":"First witness: [Full name], [Job title or capacity], telephone [Telephone number].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"0ebfe4ee-a7c4-4854-894b-057039ca26a6","value":"none","type":"remove","operator":"="}]},{"id":"349feb1d-6e38-4398-9358-f8ac9b473d36","order":101,"text":"Statement: [Record the account of the witness]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"15","cflou":false,"active":true,"displayConditions":[{"field":"0ebfe4ee-a7c4-4854-894b-057039ca26a6","value":"none","type":"remove","operator":"="}]},{"id":"d7408aa9-e380-445e-b774-beae81166662","order":102,"text":"Second witness: [Full name], [Job title or capacity], telephone [Telephone number].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"0ebfe4ee-a7c4-4854-894b-057039ca26a6","value":"two","type":"add","operator":"="},{"field":"0ebfe4ee-a7c4-4854-894b-057039ca26a6","value":"three","type":"add","operator":"="}]},{"id":"80051dde-01d7-4293-980a-ea5bbc3d46db","order":103,"text":"Statement: [Record the account of the witness]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"15","cflou":false,"active":true,"displayConditions":[{"field":"0ebfe4ee-a7c4-4854-894b-057039ca26a6","value":"two","type":"add","operator":"="},{"field":"0ebfe4ee-a7c4-4854-894b-057039ca26a6","value":"three","type":"add","operator":"="}]},{"id":"0d5f826d-7e4b-4a1e-be3e-9144c04f08bb","order":104,"text":"Third witness: [Full name], [Job title or capacity], telephone [Telephone number].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"0ebfe4ee-a7c4-4854-894b-057039ca26a6","value":"three","type":"add","operator":"="}]},{"id":"ed068106-d666-4ce4-978d-7ce9a835f004","order":105,"text":"Statement: [Record the account of the witness]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"15","cflou":false,"active":true,"displayConditions":[{"field":"0ebfe4ee-a7c4-4854-894b-057039ca26a6","value":"three","type":"add","operator":"="}]},{"id":"43ee5d97-deac-4995-bf35-bf9b021c45d2","order":106,"text":"A witness who gives an account under this heading does so in the discharge of the Employer's duty to investigate, and no adverse action shall be taken against any person by reason of the content of an account honestly given.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"0ebfe4ee-a7c4-4854-894b-057039ca26a6","value":"none","type":"remove","operator":"="}]},{"id":"302a979b-2c15-4cdf-a75c-45820e9bc85d","order":107,"text":"No person is required to give an account. Where the workforce of the Establishment is represented and an interview is one which the person interviewed reasonably believes may lead to disciplinary action, that person is entitled, on request, to the presence of a representative, and the interview is deferred until a representative can attend.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"0ebfe4ee-a7c4-4854-894b-057039ca26a6","value":"none","type":"remove","operator":"="}]},{"id":"290a3754-6d2e-43b7-8a7f-edef8b9582e0","order":108,"text":"12. IMMEDIATE RESPONSE, SCENE CONTROL AND PRESERVATION OF EVIDENCE","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S12"},{"id":"3b8747f3-db58-426d-98bb-96f2a0965df4","order":109,"text":"The immediate action taken following the incident was as follows: [Describe the first aid or medical assistance given, the shutting down or isolation of equipment, the evacuation of the area and any other immediate measure]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"da04ccf6-5936-4993-8a8d-3a454ac656a8","order":110,"text":"The scene was secured by [Name and title], on [Date and time at which the scene was secured]. Physical evidence relating to the incident is retained at [Location at which the physical evidence is retained].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"afa3fe9f-9342-435b-9110-bb238a0767c9","order":111,"text":"Photographs or video recordings of the scene have been taken, and the equipment, tool, vehicle or material involved has been withdrawn from service and retained.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"94ea6122-1653-41e1-b0d8-d9468d11869c","order":112,"text":"The Employer shall preserve all documents, records, data, photographs, recordings, monitoring results and physical items relating to the incident, and shall suspend any routine practice of destruction affecting them, until satisfied that no investigation, claim or proceeding to which they may be relevant remains reasonably foreseeable.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"e70f66c7-9ac1-4924-8ef6-75025265f2e3","order":113,"text":"Post-incident testing for drugs or alcohol was not conducted in connection with this incident.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"68982162-1cdd-42b0-8ac7-7b9a5719bca0","order":114,"text":"13. POST-INCIDENT SUBSTANCE TESTING","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","displayConditions":[{"field":"3201c1c5-1d39-49f1-8bca-875c01798b64","value":"was conducted","type":"add","operator":"="}],"sectionNum":"S13"},{"id":"926b4e53-bbbe-4fb8-890e-c13240f5e0ab","order":115,"text":"Specimens were collected on [Date and time of specimen collection] by [Name of the collection site or testing facility]. The testing consisted of a test for drugs, and the result was negative.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"3201c1c5-1d39-49f1-8bca-875c01798b64","value":"was conducted","type":"add","operator":"="}]},{"id":"197706db-78be-4a61-ba72-a935e79025b1","order":116,"text":"Testing was carried out in accordance with the written substance policy of the Employer and with applicable Federal and State law. Testing is not used, and shall not be used, as a means of retaliating against any person for reporting a work-related injury or illness, and the selection of persons for testing was made on grounds related to the circumstances of the incident and not to the making of the report.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"3201c1c5-1d39-49f1-8bca-875c01798b64","value":"was conducted","type":"add","operator":"="}]},{"id":"d8c6bc92-f302-4b2e-a438-5220396675e0","order":117,"text":"Where the law of the State in which the Establishment is situated restricts or conditions post-incident testing, that law prevails and the policy of the Employer is applied only to the extent that it permits. The result of any test is treated as confidential medical information and is kept in the confidential medical file.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"3201c1c5-1d39-49f1-8bca-875c01798b64","value":"was conducted","type":"add","operator":"="}]},{"id":"59f527df-5743-4e0b-9c4c-cb7172978c1a","order":118,"text":"14. ROOT CAUSE ANALYSIS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S14"},{"id":"6870a6d2-c037-47d9-bf18-1c4e43c7b313","order":119,"text":"The purpose of this analysis is to identify the causes of the incident so that the recurrence of the same or a similar incident may be prevented. It is not an allocation of blame, and no part of it is to be read as an admission of liability by the Employer or by any person.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"c84b8ff1-4088-4749-b74b-c6857e1dbca0","order":120,"text":"The method of analysis applied was the five whys technique.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"606edc77-0161-4f4a-a5db-9ac0af9cfbe5","order":121,"text":"The immediate causes identified are as follows: [Describe the unsafe acts, unsafe conditions, equipment failures or other immediate causes]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"7187daa6-734c-4e11-985c-dc91d8fc9210","order":122,"text":"The contributing factors identified are as follows: [Describe the contributing factors, such as workload, supervision, training, communication, environmental conditions, maintenance or time pressure]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"7add4575-88e4-4cde-adaa-0011f6a7d362","order":123,"text":"The root cause or causes identified are as follows: [State the underlying cause or causes, being the failures which, if corrected, would prevent recurrence]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"de21daf3-1b60-4f1d-9284-e08eb2db8cd3","order":124,"text":"The following deficiencies in the safety management system of the Employer were identified: [Describe any deficiency in hazard assessment, written procedures, training, supervision, inspection, maintenance or procurement, or state that none was identified]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"006f92f0-bbb2-472f-bbf4-a67957de941b","order":125,"text":"A written hazard assessment covering the task being performed had been carried out and was in force at the date of the incident. Where none was in force, or where it did not address the circumstances of this incident, one shall be prepared or revised as part of the corrective action recorded below.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"f95601ad-c63d-48f7-bfbb-7183ffd16e9b","order":126,"text":"The analysis was completed on [Date the analysis was completed] by [Name and title of the person or persons who conducted the analysis].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"ddfce217-52c6-4416-8d0b-bd2f1b892009","order":127,"text":"15. CORRECTIVE AND PREVENTIVE ACTION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S15"},{"id":"a0446f44-909e-43a1-9b0f-b730e16d473f","order":128,"text":"Independently of any specific standard, the Employer is under a duty to furnish to each employee employment and a place of employment free from recognized hazards that are causing or are likely to cause death or serious physical harm. The corrective action recorded below is taken in discharge of that duty as well as of any applicable standard.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"5a25c679-92f7-41fe-91d2-70b39256a5c5","order":129,"text":"Corrective action is selected in accordance with the hierarchy of controls, preference being given, in order, to the elimination of the hazard, its substitution by something less hazardous, engineering controls, administrative controls including changes to procedures and supervision, and, last, personal protective equipment.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"fe453ee0-1f8d-4a55-a50f-c4432b019f5e","order":130,"text":"The interim measures taken immediately, pending completion of the permanent corrective action, are as follows: [Describe the interim measures]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"0a5425fe-6b5d-415b-9d5d-37c20240f857","order":131,"text":"Those measures were put in place by [Name and title], on [Date of implementation].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"ebaecf45-94a1-4285-b2f5-fbe9aae7ad84","order":132,"text":"The permanent corrective action to be taken is as follows: [Describe the permanent corrective action]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"3ddc3f99-3226-485b-935c-da91f4b30226","order":133,"text":"Responsibility for that action rests with [Name and title of the person responsible], and it is to be completed by [Target completion date].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"fce48b7f-0c44-41a7-8b87-5745e3c7150c","order":134,"text":"The principal control adopted is best characterized as an engineering control.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"75721815-f3fe-4c9a-83bc-4b1258b7b74d","order":135,"text":"The effectiveness of the corrective action shall be verified as follows: [Describe how effectiveness will be verified, for example by inspection, audit, observation of the task or review of subsequent incident data]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"830a728a-50b9-4d8f-8e09-5a86133a2b1e","order":136,"text":"That verification is to take place on or before [Date of verification]. Where verification shows that the corrective action has not been effective, further action shall be taken and this report shall be supplemented accordingly.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"523f6a4c-ed67-4a15-9f39-58c8a687b9c2","order":137,"text":"As regards written procedures, job hazard analyses and training material, they were reviewed and revised in light of this incident.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"0b469576-3c70-45bf-9cdb-1b2655846668","order":138,"text":"Training or re-training arising out of this incident has been delivered to the persons affected. The incident and the lessons drawn from it shall be communicated to all persons exposed to the same hazard, in a manner which does not disclose confidential medical information.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"3354319e-5ccb-468e-a01f-1bbd3f0c0c2a","order":139,"text":"16. WORKERS' COMPENSATION AND CLAIM ADMINISTRATION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S16"},{"id":"e95cdedb-7d02-475e-9844-813cff58aa4a","order":140,"text":"The Injured Person not being an employee, this incident does not give rise to a workers' compensation claim against the Employer. It shall be notified without delay to the general liability insurer of the Employer, and no first report of injury is filed under any workers' compensation law by reason of this report.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"add","operator":"="}]},{"id":"e745b20f-f9e1-4dcb-aca8-83f03a4684b3","order":141,"text":"The workers' compensation insurance of the Employer is placed with [Name of the insurance carrier or third-party administrator] under policy number [Policy number]. The claim arising out of this incident bears the number [Claim number, once assigned] and was notified to the carrier on [Date on which the claim was notified].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"16f555fa-6d21-4729-89b1-7ead0edcb182","order":142,"text":"The workers' compensation jurisdiction applicable to this claim is Alabama.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"b0fe8750-82ab-4aa5-a0d9-9d61b0dd61c6","order":143,"text":"The first report of injury required by the law of that jurisdiction was filed on [Date on which the first report of injury was filed], and the person responsible for the claim is [Name and telephone number of the claims contact or adjuster].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"03e9d63d-0768-4398-a3af-38fa0bdaa774","order":144,"text":"Where the Injured Person is supplied by, or employed by, the Other Employer, the workers' compensation claim is ordinarily made under the insurance of that employer. The Employer shall furnish to the Other Employer, promptly and without charge, such information about the incident as is needed for that claim to be made and processed.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"an employee on the Employer's payroll","type":"remove","operator":"="},{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"78cc79ff-b6b3-46b2-843f-5117cd5676a3","order":145,"text":"The deadlines for the notification of an injury to the insurance carrier and to the State agency are fixed by the law of the jurisdiction identified above. They are independent of, and in most States shorter than, the periods prescribed by 29 C.F.R. Part 1904, and the Employer shall observe whichever period expires first.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"adbc2508-8a7b-47e5-8f0d-3f53472f5082","order":146,"text":"The recording of this case under 29 C.F.R. Part 1904 is made for occupational safety and health purposes only. It does not determine entitlement to workers' compensation or to any other benefit, and it is not an admission of liability by the Employer.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"c4aab64c-aaa9-46b0-b1d7-6395c354e762","order":147,"text":"17. RETURN TO WORK AND WORK RESTRICTIONS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S17"},{"id":"937a0b7a-f284-445c-a59b-d282781ae45b","order":148,"text":"At the date of this report the Injured Person has not returned to work.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="},{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"5ae1f2ec-085a-43fb-b649-9d72fb7f8039","order":149,"text":"The Injured Person returned to work on [Date of return to work].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"afae1396-3515-4b05-848a-701a2a84c8aa","value":"has not returned to work","type":"remove","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="},{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"f0f9580d-aed5-4651-85c2-d7de379dc716","order":150,"text":"The restrictions or modified duties in force are as follows: [Describe the restrictions or modified duties and the period for which they apply]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"afae1396-3515-4b05-848a-701a2a84c8aa","value":"has returned to work under modified duties or restrictions","type":"add","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="},{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"20fedf24-fae4-46d3-bd86-edf35162ca99","order":151,"text":"The Employer shall maintain contact with the Injured Person and shall review the position at intervals of not more than fourteen (14) days until the Injured Person returns to work or the case is otherwise closed.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"afae1396-3515-4b05-848a-701a2a84c8aa","value":"has not returned to work","type":"add","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="},{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"f854e511-6a57-4add-8712-19121b5ba666","order":152,"text":"The Employer shall consider whether any reasonable accommodation is required by applicable disability discrimination law and shall engage with the Injured Person accordingly. Any medical information obtained in the course of that process is kept in the confidential medical file and is not placed in the personnel file.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="},{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"0d813257-10a2-4928-8cbe-c1bf42886c66","order":153,"text":"A return to work under modified duties does not of itself determine the classification of the case under 29 C.F.R. Part 1904. That classification is governed by the determination recorded under the heading WORK-RELATEDNESS, RECORDABILITY AND ENTRY ON THE OSHA FORMS, and the Log is amended if the outcome of the case changes.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="},{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"remove","operator":"="}]},{"id":"ee2a43b5-980c-4ceb-8dd3-5eafc4246f1b","order":154,"text":"The Injured Person having died as a result of the incident, no question of a return to work arises. The Employer shall deal with the personal representative and the dependents of the Injured Person in accordance with applicable law, shall give such assistance with any death benefit claim under the workers' compensation law as that law requires, and shall have the case entered on the Log in the column for cases resulting in death.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"add","operator":"="}]},{"id":"77956a3f-6652-4442-9a9c-edd6c79664d0","order":155,"text":"The Injured Person not being a worker at the Establishment, no question of a return to work or of work restrictions arises under this report. Any consequence of the injury or illness for the Injured Person is dealt with outside this report.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"ef7ad449-e9a3-4175-b813-9132cb1573b9","value":"a person present at the Establishment as a member of the general public and not as an employee","type":"add","operator":"="},{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="}]},{"id":"b5685b20-d9a4-495b-a970-edf095106c2d","order":156,"text":"18. STATEMENT OF THE INJURED PERSON","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S18"},{"id":"7cc603b5-580a-4556-916c-e2e7bcaa9d86","order":157,"text":"The Injured Person was invited to give an account of the incident in the words of the Injured Person. That account is recorded below without alteration.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="}]},{"id":"475c6a67-a261-4df4-bbe4-c4c8733dd56a","order":158,"text":"[Record the account of the Injured Person, or state that no account was given and why]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"15","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="}]},{"id":"abd1e679-8f05-4096-ab0c-92935e97bdc5","order":159,"text":"The Injured Person has read this section and has signed below.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="}]},{"id":"5a4a85ca-fe5a-439a-99e0-230fcaea586f","order":160,"text":"The giving or the withholding of an account by the Injured Person has no bearing on the obligation of the Employer to record and report the case, on any entitlement to workers' compensation, or on the obligation of the Employer to take corrective action.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="}]},{"id":"94056b44-747e-4080-bf17-70826dfc1491","order":161,"text":"The Injured Person having died, no account could be taken. The Employer has instead recorded the accounts of the witnesses and of those who responded to the incident, and shall provide a copy of this report to the personal representative of the Injured Person on request.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"add","operator":"="}]},{"id":"e3bf272c-f702-46bc-96eb-fa8a482451d6","order":162,"text":"19. REPORTING RIGHTS AND PROHIBITION OF RETALIATION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S19"},{"id":"0f79b878-fcb2-4593-b85a-6a47f32bda0d","order":163,"text":"The Employer has established a reasonable procedure for the reporting of work-related injuries and illnesses, has informed each employee of that procedure, and has informed each employee that employees have the right to report work-related injuries and illnesses and that employers are prohibited from discharging or in any manner discriminating against an employee for making such a report.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"4fb008f4-d125-4791-bd22-55f80f4b2a73","order":164,"text":"No requirement of any procedure of the Employer operates in a manner which would deter or discourage a reasonable employee from reporting a work-related injury or illness promptly and accurately. In particular, no incentive, bonus or disciplinary practice is applied so as to penalize the making of a report.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"c248a14b-0d26-491e-8e1d-d957c1a47ca8","order":165,"text":"The Employer shall not discharge or in any manner discriminate against any person by reason of the reporting of a work-related fatality, injury or illness, the making of a safety and health complaint, a request for access to the records kept under 29 C.F.R. Part 1904, or the exercise of any other right afforded by the Occupational Safety and Health Act. That prohibition is imposed by 29 C.F.R. § 1904.35(b)(1)(iv) and § 1904.36 and by § 11(c) of that Act.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"b83d2061-dd6b-40a7-80b8-105a481ba716","order":166,"text":"Where the Establishment is situated in a State which operates its own occupational safety and health plan approved under the Act, the recording and reporting requirements of that State apply. Those requirements are substantially identical to the Federal requirements as regards which cases are recordable and how they are recorded, and may be more stringent or supplemental in other respects. The Employer shall comply with whichever requirement is the more protective.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"b1d1d2dd-82bc-4d2c-a20c-4fa37716be74","order":167,"text":"20. RECORDKEEPING, RETENTION, CONFIDENTIALITY AND ACCESS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S20"},{"id":"75ab51da-83fe-4a75-afdf-72dbd2532335","order":168,"text":"The Log of Work-Related Injuries and Illnesses (OSHA Form 300), the privacy case list where one exists, the annual summary (OSHA Form 300-A) and the Injury and Illness Incident Reports are retained for five (5) years following the end of the calendar year which they cover. During that period the Log is updated to include newly discovered recordable cases and to reflect any change in the classification or the outcome of a case already recorded, the original entry being struck out or removed and the new information entered.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"c784e0fc-2835-4e2e-9bfb-9d11342da76e","order":169,"text":"At the end of each calendar year the Log is reviewed for completeness and accuracy, the annual summary is prepared and is certified by a company executive, and it is posted in a conspicuous place at the Establishment no later than February 1 of the following year and kept posted until April 30. Where the Establishment falls within the categories identified in 29 C.F.R. § 1904.41, the Employer shall also make the annual electronic submission of the information required from the annual summary and, where applicable, from the Log and the Injury and Illness Incident Reports.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"ecb3d3ca-1cfc-4372-8d9c-b6ef8fbf15f9","order":170,"text":"The company executive who certifies the annual summary must be an owner of the company, where the company is a sole proprietorship or a partnership; an officer of the corporation; the highest ranking company official working at the Establishment; or the immediate supervisor of that official. A certification by any other person does not satisfy 29 C.F.R. § 1904.32. Where a form other than the OSHA Form 300-A is used as the annual summary, it must also carry the employee access and employer penalty statements which appear on that form.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"6988b2a1-5e92-4046-b488-5c3f1d69a2eb","order":171,"text":"Employees, former employees, their personal representatives and their authorized employee representatives are entitled to access the injury and illness records of the Employer. A copy of the relevant Log is provided by the end of the next business day following the request, with the names left on it. A copy of an Injury and Illness Incident Report describing an injury or illness to the person making the request is provided by the end of the next business day. Where an authorized employee representative requests copies of Incident Reports for the Establishment, copies limited to the section which describes the case are provided within seven (7) calendar days. No charge is made for those copies when they are first provided.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"3b02cbc0-053e-4991-aef1-1813d3ad2355","order":172,"text":"Copies of the records kept under 29 C.F.R. Part 1904 are provided to an authorized government representative within four (4) business hours of the request.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"7a758ad7-c3d5-457d-87b6-ddffcd35274f","order":173,"text":"This report is disclosed to a person other than a government representative, an employee, a former employee or an authorized representative only with the personally identifying information removed, save that it may be disclosed with that information to an auditor or consultant engaged to evaluate the safety and health program, to the extent necessary for the processing of a claim for workers' compensation or other insurance benefits, or to a public health authority or law enforcement agency to the extent permitted by law.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"d27f51f1-498b-4058-ac43-7384a09e2f89","order":174,"text":"21. CERTIFICATION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"24","sectionNum":"S21"},{"id":"bae80e0e-665d-46d3-9ee6-76e4b87fab42","order":175,"text":"The person who completed this report certifies that the information recorded in it is, to the best of that person's knowledge and belief, complete and accurate, and that the account of the incident has been recorded as it was given.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"968899a8-ac9a-40b8-8ac9-e470d1411685","order":176,"text":"Completed by: [Full name], [Job title], telephone [Telephone number].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"0e7ab8d5-9a38-4ddc-8537-42d05ed8068b","order":177,"text":"Signature: ______________________________ Date: [Date of this report]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"fa079dc3-f24e-4a75-8a98-4165d804b956","order":178,"text":"Reviewed by the supervisor or manager responsible: [Full name], [Job title].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"dd1c440f-452a-4352-94a7-53ecffa9d6ca","order":179,"text":"Signature: ______________________________ Date: ______________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"222a0c90-8d41-4d54-83b2-23340f691dc2","order":180,"text":"Reviewed by the person responsible for safety and health at the Establishment: [Full name], [Job title].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"91f1ebda-f6e2-425f-9718-0fddf2322620","order":181,"text":"Signature: ______________________________ Date: ______________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"95772986-37d5-45b1-accf-648c91ac7e0a","order":182,"text":"Acknowledged by the Injured Person: [Full name]. Signature of the Injured Person acknowledges receipt of a copy of this report and does not constitute agreement with its contents.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="}]},{"id":"d7e7db05-23af-415b-aee5-1cdacc33cc4e","order":183,"text":"Signature: ______________________________ Date: ______________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"remove","operator":"="}]},{"id":"0f910235-f0ee-40fd-a531-9daaae287cec","order":184,"text":"Copy of this report provided to the personal representative of the Injured Person, on request and subject to applicable law.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"add","operator":"="}]},{"id":"efdc8684-e606-48c3-a1d8-0bcc04a0e0de","order":185,"text":"Received by: ______________________________ Date: ______________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"292b1635-37b6-4281-a797-9ffcfa5fb792","value":"is work-related and recordable as a fatality","type":"add","operator":"="}]}]