OSHA Form 200

U.S. Department of Labor

	For Calendar Year 19____	Page ___ of ___	
Company Name		Form Approved	
Establishment Name		O.M.B. No. 1220-0029	
Establishment Address			
Extent of and Outcome of INJURY	Type, Extent of, and Outcome of ILLNESS	
Fatalities	Nonfatal Injuries	Type of Illness	Fatalities	Nonfatal Illness	
Injury
Related
	Injuries With Lost Workdays	Injuries Without Lost Workdays	CHECK Only One Column for Each Illness (See other side of form for terminations or permanent transfers.)	Illness Related	Illnesses With Lost Workdays

	Illnesses Without Lost Workdays	

Enter DATE of death.

Mo./day/yr.

	
Enter a CHECK if injury involves days away from work, or days of restricted work activity, or both.	
Enter a CHECK if injury involves days away from work.

	
Enter number of DAYS away from work.

	
Enter number of DAYS of restricted work activity.

	
Enter a CHECK if no entry was made in columns 1 or 2 but the injury is re-cordable as defined above.								
Enter DATE of death.

Mo./day/yr.	
Enter a CHECK if illness involves days away from work, or days of restricted work activity, or both.	
Enter a CHECK if illness involved days away from work.	
Enter num-ber of DAYS away from work.	
Enter number of DAYS of re-stricted work activity.	
Enter a CHECK if no entry was made in columns 8 or 9.	
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)	(11)	(12)	(13)	
						(a)	(b)	(c)	(d)	(e)	(f)	(g)							

																			

																			

																			

																			

																			

																			

   Certification of Annual Summary Totals By ___________________________________________________        Title ______________________________________      Date __________________	
	
   OSHA No. 200		   POST ONLY THIS PORTION  OF THE LAST PAGE NO LATER THAN FEBRUARY 1.	

Bureau of Labor Statistics
Log and Summary of Occupational
Injuries and Illnesses	
NOTE: This form is required by Public Law 91-596 and 
            must be kept in the establishment for 5 years. 
            Failure to maintain and post can result in the 
            issuance of citations and assessments of penalties. 
            (See posting requirements on the other side of 
            form.)	RECORDABLE CASES: You are required to record information about every occupational death, every nonfatal occupational illness, and those nonfatal occupational injuries which involve one or more of the following: loss of consciousness, restriction of work or motion, transfer to another job, or medical treatment (other than first aid). (See definitions on the other side of form.)	
Case or File Number

Enter a nondupli-cating number which will facilitate com-parisons with supple-mentary records.

(A)	Date of Injury or Onset of Illness

Enter Mo./day.

(B)	Employee’s Name

Enter first name or initial, middle initial, last name.

(C)	Occupation

Enter regular job title, not activity employee was performing when injured or at onset of illness. In the absence of a formal title, enter a brief description of the employee’s duties.

(D)	Department

Enter department in which the employee is regularly employed or a description of normal workplace to which employee is assigned, even thought temporarily working in another department at the time of the injury or illness

(E)	Description of Injury or Illness

Enter a brief description of the injury or illness and indicate the part or parts of body affected.

Typical entries for this column might be: Amputation of 1st joint right forefinger; Strain of lower back; Contact dermatitis on both hands; Electrocution—body.

(F)	
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					TOTALS (Instructions on other side of form)