U.S. Department of Labor	
Bureau of Labor Statistics	
Supplementary Record of	
Occupational Injuries and Illnesses	
This form is required by Public Law 91-506 and must be kept in the establishment for 5 years.  Failure to maintain can result in the issuance of citations and assessment of penalties.	Case or File No.	          Form Approved
O.M.B. No. 1220 0029	
Employer	
   1.  Name	
	
   2.  Mail address (No. and street, city or town, State, and zip code)	
	
   3.  Location, if different from mail address	
	
Injured or Ill Employee	
   4.  Name (First, middle, and last)	Social Security No.	
										
   5.  Home Address  (No. and street, city or town, State, and zip code)	
	
   6.  Age	7.  Sex: (Check one)	
 				Male         Female  	
   8.  Occupation (Enter regular job title, not the specific activity he was performing at time of injury.)	
   	
   9.  Department (Enter name of department or division in which the injured person is regularly employed, even though 
       he may have been temporarily working in another department at the time of injury.)	
	
The Accident or Exposure to Occupational Illness	
   If accident or exposure occurred on employer’s premises, give address of plant or establishment in which it occurred. 
   Do not indicate department or division within the plant or establishment.  If accident occurred outside employer’s
   premises at an identifiable address, give that address.  If it occurred on a public highway or at any other place which
   cannot be identified by number and street, please provide place references locating the place of injury as accurately as
   possible.	
   10.  Place of accident or exposure (No. and street, city or town, State, and zip code)	
	
   11.  Was place of accident or exposure on employer’s premises?	
							Yes         No  		
   12.  What was the employee doing when injured? (Be specific.  If he was using tools or equipment or handling material,	
          name them and tell what he was doing with them.)		
	
   13.  How did the accident occur?  (Describe fully the events which resulted in the injury or occupational illness.  Tell )	
          what happened. Name any objects or substances involved and tell how they were involved.  Give full details on all	
          factors which led or contributed to the accident.  Use separate sheet for additional space.)		
	
Occupational Injury or Occupational Illness	
   14.  Describe the injury or illness in detail and indicate the part of body affected. (E.g., amputation of right index finger 
         at second joint; fracture of ribs; lead poisoning; dermatitis of left hand, etc.)	
	
   15.  Name the object or substance which directly injured the employee.  (For example, the machine or thing he struck 
          against or which struck him; the vapor or poison he inhaled or swallowed; the chemical or radiation which irritated 
          his skin; or in cases or strains, hernias, etc., the thing he was lifting, pulling, etc.)	

   16.  Date of injury or initial diagnosis of occupational illness	17.  Did employee die? (Check one)	
				             Yes         No  	
Other	
   18.  Name and address of physician	
	
   19.  If hospitalized, name and address of hospital	

Date of Report	Prepared by	Official position	
			
OSHA No. 101 (Feb. 1981)