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California Code of Regulations (Last Updated: August 6, 2014) |
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Title 8. Industrial Relations |
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Division 1. Department of Industrial Relations |
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Chapter 7. Division of Labor Statistics and Research |
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Subchapter 1. Occupational Injury or Illness Reports and Records |
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Article 2. Employer Records of Occupational Injury or Illness |
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Appendix E. - Required Elements for the Cal/OSHA Form 300A, Annual Summary of Work-Related Injuries and Illnesses Equivalent Form. |
Appendix E. - Required Elements for the Cal/OSHA Form 300A, Annual Summary of Work-Related Injuries and Illnesses Equivalent Form.
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A. Employers who are required to complete the Cal/OSHA Form 300A may use an equivalent form that provides all of the following information: 1. The number of cases: (G) The total number of deaths (H) The total number of cases with days away from work (I) The total number of cases with job transfers or restriction (J) The total number of other recordable cases 2. The number of days: (K) The total number of days away from work (L) The total number of days of job transfer or restriction (M) Injury and Illness Types, the total numbers of: 1. Injuries 2. Skin disorders 3. Respiratory conditions 4. Poisonings 5. Hearing loss 6. All other illnesses 3. Posting requirement statement: “Post this Annual Summary from February 1 to April 30 of the year following the year covered by the form.” 4. Establishment information: • The establishment name • Street address • City, State, Zip • Industry description • The Standard Industry Classification Code, if known. 5. Employment information • The annual average number of employees. • The total hours worked by all employees last year. (For assistance in calculating the annual average number of employees, and total hours worked, refer to Appendix G.) 6. Sign Here: • Admonition: “Knowingly falsifying this statement may result in a fine.” • Certification statement: “I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete.” • Space for the signature of the company executive, and title. • Phone number of signatory. • Date of the certification. |