Document aB84y05go0GXdpOq2bbNM8kD9

249568 i OSHA NO. 100 LOG OF OCCUPATIONAL INJURIES AND ILLNESSES Form Approved OM8 NUMBER 44R 1455 ' 0035I7 OSHA NO. 100 LOG OF OCCUPATIONAL INJURIES AND ILLNESSES Form Approved OMB NUMBER 44RUSZ 003516 249570 05HA NO. 100 LOG OF OCCUPATIONAL INJURIES AND ILLNESSES Form Approved OMB NUMBER 4-5R H5I 003519 249571 OSHA NO. 100 LOG OF OCCUPATIONAL INJURIES AND ILLNESSES Form Approved OMB NUMBER 44R 145? 249572 OSHA NO. 100 LOG OF OCCUPATIONAL INJURIES ANO ILLNESSES Form Approved OMB NUMBER 44R 1455 249573 OSHA NO. 100 LOG OF OCCUPATIONAL INJURIES AND ILLNESSES Form Approved OM8 NUMBER 44R M5S ' 003522 249574 OSHA NO. 100 LOG OF OCCUPATIONAL INJURIES AND ILLNEr.`.:3 Form Approved OMB NUMBER 44R 145: } OSKA NO. 100 LOG OF OCCUPATIONAL INJURIES AND !LUEf.~ZS G Form Approved OMB NUMBER 44R 14X Company Name --...__.... bllabaect Name ...... Establishment Location Injury Code 10 All oeecpelleail injaricj Ulneu Cadet 21 Occupational akia dsK**e or dltorden 2S Duotden dts lo pbyiieal agents (other thin 22 Duot disease* of the Jang* (pneumoconioses) loilc aiterieli) 23 Respiratory conditions duo to totic agent* 26 Dborder* dne to reputed lusts* Zi Poisoning (Spumle effects of toiic materials) 29 All other occspiiional lUaeuet 003525 249577 OSHA NO. 100 LOG OF OCCUPATIONAL INJURIES AND 1LLNEJT.I3 Form Approved Om NUMBER 44R 145i 003526 OSHA NO. 100 . LOG OF OCCUPATIONAL INJURIES AND 'LL-'Ef - 3 c foTM Approved OMB NUMBER 44R US' 0035^7 249579 (a i OSHA NO. LOG OF OCCUPATIONAL INJURIES AND ILLNESSES . o S3 SSSStzo OMB NUMBER 44R 1453 003528 I | | ! ' , `' . '* , I- . , 1 , ... ' ' I. .. i 1 j I . { i 1 RECORDKEEPING REQUIREMENTS Regulations issued under the Occupational Safe!]' and Health Act of 1970 require all establishments subject to the Ad to maintain records of recordable debyde, plasties and rests*, etc, (25) Disorders Due to Physical Agents (Other Than Toxic Materials) Example; Heatstroke, sunstroke, beat eibausnots and other effects o! eavitonmeatsl heat; freezing, frostbite occupational Injuries and illnesses occuring on or after July 1,1971. Such records must consist of: a) a log of occupational Injuries and illnesses; b) a sup plementary record of each occupational Injury and illness; and c) an annual summary of occupational and effects of exposure to low temperatures; caisson disease; effects of ionizing radiation (Isotopes, X-rays, radium); effects of nonSaziag radiation (welding Bath, ultraviolet rays, microwaves, sunburn), etc. (26) Disorders Doe to Repealed Trauma Examples: Nobe-lodueed bearing Joss; synovitis, Uao- Injuries and illnesses. Recordkeeping requirements under the Occupa tional Safety and Heatlb Act may differ from your Stato workmen's compensation requirements. Please review the definitions contained in this form to be sure that records are being maintained for all record synontu, and bursitis: Raynaud's phenomena; and other conditions due to repeated motion, vibration or pressure. (29) All Other Occupational Illnesses Examples: Anthrax, brucellosis, infectious hepatitis, malignant and benign tumors, food poisoning, histo plasmosis, coccidioidomycosis, etc. able cases. DEFINITIONS . OCCUPATIONAL INJURY b any injury such as a cut, fracture, sprain, amputation, ett, which re* suits from a work accident or from exposure in the work environment. OCCUPATJ QNAL ILLNESS of an employee Is any RECORDABLE OCCUPATIONAL INJURIES AND ILLNESSES are aay occupational injuries or 21- nesses which result in: 2) FATAUTIES, regardless of tbe lime between the {n]ary and death, or the length ( the Dlaess: or 2) LOST WORKDAYS CASES, ther'tbsn fatalities that mult tu lest workdays; or v . 3) NONFATAL CASES WITHOUT LOST WORKDAYS, abnonriaV'condition or disorder, other than one resulting Jroman occupational Injury, caused by exposure to environmental factors associated with'His employment. It includes acute and chronic illnesses or diseases which may be caused by inhalation, ab -- which result in transfer to nnother job or termination of empiopaear, or require medical treatment (as defined < below), or Involve lota ol consciousness or restriction of work or motion. This category also Includes any diagnosed occupational which are reported to tbe cm, ploycr hot are not classified aa (stabile* or lost workday - sorption, ingestion, or direct^ contact, and which can be included'in the categories listed below. ' Hie following listing gives the categories of occupational illnesses and disorders that will be utilized for the purpose of classifying recordable illnesses. " MEbfCAL TREATMENT includes ireaimenVad&aiaiered f by a physician or by registered professions! personnel under tbo standing orders of physician. Medical treatment does NOT include first aid trcataseat (one-time treatment and aubsequcal observation of miner scratches, cuts, hums, splinters, lie Identifying codes are those to be used in Column and so forth, Which do not ordinarily require medical care) 7 of the log. For purposes of information, examples of each category are given. These are typical exam* pies, however, and are not to be considered to be the complete listing of the types of illnesses and disorders that are to be counted under each category. even though provided by c physician or registered professional personnel ESTABLISHMENT: A single physical location where bush ocas is conducted or where services or indsstrial operations are performed. (For example: a factory, mill, store, boteL * laoraat, movie theater, farm, ranch, bank, siles office, ware (21) Orcopjlltiitl Skin Direne* or Disorder* Disables: Centaet deraaatllls, eczema, or nth caused by primary irritants and utiiilim or poitoaoos plants; til acne; chrome ulcers; chemical buna or InHammslions; etc. (22) Das! Diseases of the Lonpa (Pitunocenieses) Examples: SHIcosIt. asbestos!*, coal worker's poenmocontasls. bytsfaoils, sod other pneumoconioses. (23) Respiratory Conditions Dae to Toxic Agents house or etaixt) administrative office.) Where distinctly separate activities are performed at a single physical location (such as contract constusetson activities operated from the same physical location as a lumber yard), each activity shall be treated as a separate establishment. For firms engaged in activities sueh as apiculture, eon* siruction, transportation, communications, and electric, get and sanitary services, which may he physically dispersed, records may be maintained at a place to which employee* Examples: PaeomoeitU, pharyngitis, rhinitis or aente - dbngettlon don to chemical), dials, gases, or fomea; farmer's long; etc. report each day, ' Records for personnel who do not primarily report or work at a single establishment, such as traveling salesmen, tech (24) Poisoning (Systemic EEfectsol Toxic Materials) nicians, engineers, etc, shit] be maintained at tbe location Examples: Poisoning by lead, mercury, ar from .which they ire paid ov the base from which personnel senic, nr ether metals,' poisoning by carbon monoxide, hydrogen sulfide or ether gases; poisoning by bexoal, carbon tetrachloride, or ether organic solvents; poison ing by insecticide sprays sueh as ^aratbloa, lead operate to cany out their activities. WORK ENVIRONMENT is comprised oi the physical loca tion, equipment, materials processed or used, and the kinds of operations performed by aa employee in tbe performance of arsenate; poisoning by other chemicals such as formal. hi* work, whether en or off the employer's premises- LOG OF OCCUPATIONAL INJURIES AND ILLNESSES Each recordable occupational injury and occupational illness must be entered on a log of cases (OSHA Form No. 100) with in two working dsys of receiving information that a recordable case has occurred. Lop must be kept current and retained for five <S) yean following tbe end of the calendar year to which they relate. Lop are to be maintained for three purposes: 1) Lop for the prior five (5) year period must be available in tbe establishment without delay and at reasonable limes for examination by representatives ol the Department of Labor or the Department of Health, Education and Welfares or State* accorded jurisdiction under tbe Act. 2) Tbe log will be used la preparing the annual summary oi Occupational Injuries and Illnesses (OSHA Form No. 102) whieh must be posted in every establishment. 3) There establishment* selected to participate la a statiitical program will be required to prepare a report based on entries in this tog. In addition, lha log will aid you Sa reviewing the occupation al injury and illness experience ol yarn employees. INSTRUCTIONS FOR COMPLETING LOG OF OCCUPATIONAL INJURIES AND ILLNESS (OSHA Form No. 100) Colama 1 - CASE OR F1LE NUMBER Any number may be entered which will facilitate compa'nion with supplementary records. Column 2 - DATE OF INJURY OR ILLNESS For occupational injuries eater the dste of the work accident which resulted in Injury2 FordcciiRational Illnesses enter the date el Initial diagnosis of Illness, or, H absence occurred before diagnosis, the first day of the absence In connection with which the case was diagnosed. Column 3 EMPLOYEE'S NAME Column 4 OCCUPATION Enter the occupational title of the Job to which the em ployee was assigned at the time of injury or illness. In the absence of a formal occupational title, eater brief descrip tion ol the dau'es ei the employee. Column 5 DEPARTMENT . Enter the name of the department to which employee was assigned at the lime of injury ex Hines*, whether or not em ployee was actually working in that department at the time. In the absence ef formal department titles, eater a brief description of normal workplace to which employee la assigned. Column 6 NATURE OF INJURY OR ILLNESS AND PART(S) OF BODY AFFECTED Enter brief description of the injury or Illness and Indicate the part or parts of body affected. Where entire body la affected, the entry ''body** cam be used. Column 7 INJURY OR ILLNESS CODE Enter tbe one code which most neeurately describes the nature of Injury or Illness. A list of code* appears at the boUem of the log. A more complete description ef occnpa. tional injuries end illnesses appears below la "definition*.' Column 8 - FATALITIES JJ the occupations! injury nr illness resulted in death, enter title ef death. ' Column 9 - LOST WORKDAYS Enter the number of days Ibe empUyee would have worked but could not because ef occupational injury or illness. The number ef Ion woikdap should not belnd* tbe day of Injury. The number ol days includes all days (consecutive er not) oo whieh, because ef the injury or illness: 1) the employee would have worked bat could not, or 2) the employee wai assigned to temporary Job, or 3) the employee worked at permaaeat job less thta fall lime, or 4) the employee worked at a permanently assigned job hot could not perform all deties normally resigned re it- . _ For employees net baring a regularly scheduled ihllC'Xe-, . certain truck driven, eooitructkn workers, farm labor, casual labor, part-time employees, etc. it may be necessary te estimate the number el lost workday*. Estimates of lost workdays shall be based oa prior work history oi the cm- * ployee AND day* worked by employee*, not 1) or injured, werllsg fa the department aod/cr oeespatsoa el t&e.il! or injured employee . Column 10 - PERMANENT TRANSFER TO AN OTHER JOB OR TERMINATION OFEMPLOY MENT AFTER LOST WORKDAYS' ~ Complete only if tbe employee did not return to his previous, assignment after lost workday*. " ", ~ Column 11 - NONFATAL CASES WITHOUT LOST WORKDAYS. Eater a check b Column 11 for all cases ei occupational injury or tttovy-, which did not involve fatalities or lost workdays but Ad resoll'ia: --Transfer to another Job or termination oi emplajm^t, or_^_, --Medical treaimesvother tbjjrfirU'aS, er ' --Diagnosis of eeeepatieaal Hines*, er .. --Loss ef consciousness, or --Restriction ol work or motion, eater a check Sa Column 11. Column 12 TRANSFER TO ANOTHER JOB OR TERMINATION OF EMPLOYMENT WITHOUT - LOST WORKDAYS . If the rb"k fa Column 11 represcalcd a transfer to another fob er.letmlaatioa of employment with `no lost workday*,' .eater another cheek in Column 12. INITIALING REQUIREMENT ' '' Each line entry regirding an occupational bjuxy er illness MUST BE INITIALED b the right hand margin by the person responsible for the accuracy of the entry. Change* , in in catty also must be Is!tilled ia the affected.colttmn. . CHANGES IN EXTENT OF OR OUTCOME OF . INJURY OR ILLNESS . If there 1* a change ia aa occupational injury or Ubess ease which affects entries In Columns 9, 14 11, er 1% the firet entry ihould be lined out nad a new entry-made. For ex ample, If an injured employee at fint requited enfy medical treatment bet later lest workday*, the cheek la Colnmn 11 shonld he lined out and the number ef loot workdays entered in Column 9. ._ In another example. If aa employee with an occupational Utaeaa lost wetkdaya. retained to work, and thea died of the Qbem, the workday* noted la Cotsma 9 ibotld be lined out and the dale of death entered b Colnmn 8. An enuy may be Laed out if later found to be a non* occupational injury or illness. 249581 00351' fo Iosha' -a. 100 LOG OF OCCUPATIONAL INJURIES AND ILLNESSES o nuwber44R U53 249582 003531 249583 RECORDKEEPING REQUIREMENTS Regulations issued under Ihe Occupational Safety and Health Act of 1970 require all establishments subject to the Act to maintain records of recordable occupational Injuries and illnesses oeeuring on or dehyde, plasties and resins, etc. ., (2S> Disorder* Dae to Physical Agents (Other'Than Toxic Materials) - , ' Example: Heatstroke, sunstroke, beat exhaustion and other effects si environmental beat; (raring, frostbite and effects o( exposure la low temperatures; caisson after July 1,1971. Such records must consist of: a) a log of occupations! injuries and illnesses; b) a sup plementary record of each occupational injury and illness; and c) an annual summary of occupational injuries and illnesses. disease; effects o( ianiring radiation {isotopes. X-rays, radium); effects el nonioring radiation (welling flash, ultraviolet ttys, microwares, nature), etc, (26) Disorders Dae to Repeated Trauma Examples: Noise induced hearing fats; synovitis, teno synovitis, and bursitis; Saynand'a phenomena; and Recordkeeping requirements under tbe Occupa tional Safety and Health Act may differ from your State workmen's compensation requirements- Please review the definitions contained in this form to be sure that records are being maintained for all record other conditions due to repeated motion, vibration or pressure. (29) All Other Occupational Illnesses Examples' Anthrax, brucellosis, infectious hepatitis, malignant and .benign turnon, food poisoning, histo plasmosis, coccidioidomycosis, etc. able cases. RECORDABLE OCCUPATIONAL INJURIES AND DEFINITIONS OCCUPATIONAL INJURY b any injury such as ILLNESSES are. any occupational injuries or ill nesses which result in: n cut, fracture, sprain, amputation, etc^ which re sults.from a work accident or from exposure in the work environment. OCCUPATIONAL ILLNESS of an employe* [a any abnormal condition or disorder, other than one 1) FATALITIES, regardless of the time between the Injury and death, or the length of the illness; or 2) LOST WORKDAYS CASES, other than fatalities that result ha lost workday*: or 3) NONFAYAL CASES WITHOUT LOST WORKDAYS, vbleh result la transfer to another Job or lamination of resulting from an occupational injury, caused by ex* posuro to environmental factors associated with his employment. It includes acute and chronic illnesses or diseases which may be caused'by inhalation, ab sorption, ingestion, ox dhcet contact, and which can employment, or require medical treatment <aa defined * below), or iavolve loss of eonsdouadets or restriction el work or motion. This category also ineludes any diagnosed occupational illnesses wkteb are repotted to the em ployer bat are not classified as fatalities or lost workday cases. ' be included in the categories listed below. MEDICAL TREATMENT Includes treatment administered i The following listing gives the categories of occu by a physician or by registered professional personnel under s I pational illnesses and disorders that (rill be utilized for the purpose of classifying recordable illnesses. The identifying codes are those to he used in Column the standing orders o( a physician. Medical treatment does NOT include first aid treatment (oootimo treatment and sub sequent observation of minor scratches, cuts, bums, splinters, and so forth, which do not ordinarily require medical cart) 7 of the log. For purposes of information, examples even'though ptorided by n phyalciao or registered professional i of each category are given. These are typical exam personnel, ples, however, and are not to be considered to be the complete listing of the types of illnesses and dis orders that are to he counted under each category. ESTABLISHMENT: A single physical location where busi ness is conducted or where services or Industrial operations arc performed. (For example: factory, mill, store, bold, res taurant, movie theater, (arm, ranch, bank, talcs office, ware (21) Occupational SUa Duetto* or fHsdrTe'is house, or central administrative office.) Where distinctly . Examples: Contact dermatitis, ccscma, w p*h earned separate activities ire performed at a aingie physical location by primary Irritant! and scasitbenor poisonous plants: (such as contract construction aetiritUt operated from the oil acne; chrome ulcers; chemical bums or Inflamma came physical location as a lumber yard), each activity shall tion!; etc. he treated at a separate establishment * (22) Dust Diseases of tho Lungs (Paeumocoaioses) For firms engaged la actiritlcs sack as agriculture, con Examples: Silicosis, ashestosis, coal worker's pneumo struction, transportation, communications, and electric, gss coniosis, bpsbosis, sad other pneumoconioses. and unitary serried, which may be phytlcaBr dispersed, (22) Respiratory Conditions Doe to Toxic Atents records rosy be matacsined at a place to widen employees ' Examples: Pneumonitis, pharyngitis. rhinitis or aente report each day. congestion due to chcmktls, dusts, cases, or fames; Records for personnel who do not primarily report or wotk (inner`a luogi etc. at single establishment, such as traveling salesmen, tech (24) Palsoniag (Systemic Effects o( Toxie Materials) nicians, engineers, etc, shat! be maintained at the location Examples: Poisoning by lead, mercury, ftdryd|l*r, ar- from which they aie paid or the base from which personnel aenie, or other metals, poisoning by carbon monoxide, operate to cany out their activities. hydrogen sulfide or other gases: poisoning by beared, WORK ENVIRONMENT is comprised o( the physical loca carbon tetrachloride, or other organic solvents; poison- tion, equipment, material* processed or used, and the kinds o( fag hr insecticide sprays such as paratbion, lead operations performed by an employee fa the performance of arsenate; poisoning hr other chemicals such as forms!- his wotk. whether on or off the employer's premises. LOG OF OCCUPATIONAL INJURIES AND ILLNESSES Each recordable occupational Injury`and occupational illness most be entered on a log ol cases (OSHA Form No. 100) with in two working days oi receiving information that recordable case has occurred. Logs must be kept current and retained far five (S) yean following the end of the calendar year to which they relate. Logs art to he maintained (or three purposes: 1) Logs for the prior five (S) year period must be ovailahle in the establishment without delay and at reasonable limes far examination by representatives of the Department of Labor or ihe Department of Health, Education and Welfare, or States accorded farisdictian imderthe Act. 2) The lag wsB be used U preparing the annual summary ei Occupational Injuries and Illnesses (OSHA Form No. 102) which must be posted fa every establishment. 3) Those establishment* selected to participate fa a rtstisti* ea] program wM be required to prepare a report based on entries la this log. fa addition, the log will aid you fawdriewing the occupation al injory ood illness experience of your employees. INSTRUCTIONS FOR COMPLETING LOG OF OCCUPATIONAL INJURIES AND ILLNESS (OSHA Form No. 100) Column I - CASE OR FILE NUMBER Any number may be entered which wiU facilitate comparison with supplementary records. Column 2 - DATE OF INJURY OR ILLNESS Fox occupationsi injuries enter the date ol the wotk accident which resulted in fafnry. For occupational illnesses enter the dote of initial diagnosis of Ufaess, or, If absence occurred before diagnosis, the first day of the absence in connection with which tbe ease was disposed. Column 3 EMPLOYEE'S NAME Column 4 - OCCUPATION Enter the occupational title of the fob to which the em ployee was assigned at the time of Injury or illness. In tbe absence of a formal occupational title, enter a brief descrip tion of the duties of the employee. Column S - DEPARTMENT Enter tjie name of tbe department to whieh employee was assigned at the time oi injury or tllscss, whether ox not em ployee was actually working fa' that department at the rime. In (he absence of formal department titles, enter a brief description of norrat) workplace to wbieh employee is Column 6 - NATURE OF INJURY OR ILLNESS AND PART(S) OF BODY AFFECTED *. Enter a brief description of tbe injury or Bloess and indicate the part or parts of body affected. Where entire body is sffccled, the entry "body" can be used. ; Column 7 - INJURY OR ILLNESS CODE Enter ihe one code whieh most accurately describes the nsture of injury or illness. A Irst of codes sppears at the bottom of tbe log. A men complete description c( occupa tional injuries and illnesses sppears below in "definitions." Column 8 - FATALITIES , If tbe oecupstiona) injury or illness resulted in dcslh, enter date of death. Column 9 - LOST WORKDAYS Enter tbe number of days the employee would have worked but could not because of occupational injury or illness. Tbe number of lost workdays should not include the day of iajury. The number of dap isdodc* all dap (consecutive or not) on which, because el the in]ary or Illness: 1) the employee woald hsve worked but ceold not, or 2) the employee wsa assigned to a temporary job, or 3) the employee worited at a permanent job iesa than full 4) the employee worked at a permanently assigned jab but could not perform all duties normally assigned to it. For employee* not haring a regularly scheduled shift, fa, certain truck drirtn, construction workers, farm labor, casual labor, part-time employees, etc, St may be necessary to estlmile tbe number of lost workdays. Estimates of lost workdap shall be based on prior work history of the cm- ployee AND dap worked by employees, not ill or injured, working in the department and/or occupation si tbe sD or injured employee. _ Column 10 - PERMANENT TRANSFER -TO AN OTHER JOB OR TERMINATION OF EMPLOY-" MENT AFTER LOST WORKDAYS Complete only il tbe employee did not retain to his previous assignment after lost workdays.. - Column II - NONFATAL CASES WITHOUT LOST WORKDAYS . Enfar a check fa Column 11 far all cases of ogcepstional injury or illness, which did not involve fauhtiesjor lost workdays but did result fa: --Transfer to another job or termination of employment, or --Medical treatment, other than first aid, or ` --Diagnosis of occupational Ulness, or v' --Loss of consciousness, or -- --Restriction ol workor motion, eater a cheek fa Column IL Column 12 - TRANSFER TO ANOTHER JOB OR TERMINATION OF EMPLOYMENT WITHOUT LOST WORKDAYS \. If the check fa Coiatan 11 represented a transfer to another job or lermfaaliea of employment with no lost workdays, enter soother check in Column 12. INITIALING REQUIREMENT '- Each line entry regarding as occupational faj'ory or illness MUST BE INITIALED fa the right hand msrgfa by the person responsible for tbe accuracy of tbe entry. Changes fa an entry also must be initialed ia the affected column. CHANGES IN EXTENT OF OR OUTCOME OF INJURY OR ILLNESS ~ If there Is a ehaage fa an occupational fajery or Blneta ease which affects entries fa Coltddw9. 10{ 11. or 12, the fint. entry should be lined out' and a new entry made. For ex- ample, il an injured employee at first required only medical treatment bat later lost workdays, tbe check fa Column 11 should be Heed out sad tbe number of lost workdap catered fa Column 9. In another example, if ao employee with an occupations! illness lost workdays, returned to wprk, sad then died of the illness, the workdap noted in Column 9 should be lined out and the dale ol death entered In Column 8. An entry may be lined out If later found to be a non- occupational injury or illness. 249584 003532 t 1 249585 r. V * iI I I ') RECORDKEEPING REQUIREMENTS Regulations issued under the Occupations! Safety and Health Act of 1970 require all establishments subject to the Act to maintain records of recordable occupational injuries sad illaesses oecuriog on or after July 1,1971. Such records must consist of: a) a log of occupational injuries and illnesses; b) a sup- piementary record of each occupational injury sod illness; and e) an annual summary of occupational injuries and Illnesses. Recordkeeping requirements under the Occupa tional Safety and Health Act may differ from your State workmen*# compensation requirements. Please review the definitions contained in this form to be sure that records are being maintained for all record able cases. DEFINITIONS OCCUPATIONAL INJURY b any, injury such as a cut, fraeture, sprain, amputation, etc., which re suits from a work accident or,from exposure in,the_ work environment. OCCUPATIONAL ILLNESS of an.employee is any abnormal condition cr disorder, other than one resulting from an occupational injury, caused by ex posure to environmental factors associated with bis employment. It fncludes_ acute andjchronic_ illnesses , -'or'd&eCiS-wlifch may be'eaused'hy inhalation, ah- sorption, ingestion, cr direct contact, and which can bo included in the categories listed below. ,, 'The iollowing listing gives the categories of occu pational illnesses and disorders that will be utilized foe. the purpose of classifying recordable illnesses. The identifying codes are those to be used in Column 7 of the log. For purposes of information, examples of each category are given. These ere typical exampies, however, and are not to be considered to be the complete listing of the types of illnesses and dis orders that are to lie counted under each category. 421) Occasional Skin Diseases or Disorders Examples: Contact dermatills, cocoa, or tut tinted by primary Irritants and seasiifaer* or poisonous plants: oil acne; chrome ulcers; chemical bums or taSamat* 422) Dust Diseases of tbo Lungs (Pneumoconioses) Examples; Silicosis, asbestos!*. coal worker's'paeumoconWtii, byufaot's, and other pwumoeontose*. 423)sRespfrttory Cbndltfofia Duo to Toxic Agent* ^ _ J ,, Exsmpfes: Pneumonitis.' pharyngitis. rhinitis or sente congestion doe to chemicals, dotes, gases: or lames; farmer'* lung; etc. 424) Poisoning (Systemic Eltccti of Toxic Materials) Examples: Poisoning by lead, mercury, cadmium, ar senic, or olher racists,* poisoning by carbon monoxide, hydrogen sulfide or other fates; poisoning by benzol, carbon tetrachloride, or other organic solvents; poisonfee by insecticide sprays tack a* pareiblen, lead arsenate; poisoning by other chemicals such at formal. dehyde, plasties and resins, etc. ' |2S> Disorders Due to Physical Agents (Other Than Toxic Ultcn'ilil Example: Heatstroke: sonttmke, bat ethinstion sad other elects el eavireamcnul beat; fretting, ftettbfte and eSecls of exposure to low lcmpert-arcs; caisson disease; cSeeu ei ioniring rtdsaiion (isotope*. X-rsys, yadlua); effects of noaiodag ndiatioff (striding flash, nlinriolet nys, microstores, seaborn), elm (26) Disorders Doe t# Repeated Trtanu Examples: Kobe-induced hearing loss; ajaovitb, lenosynovitis, and borsitis; ftayasnd'a phenomena; and other conditions doe to repealed motion, vibration or pressure. (29) AD Other Occupational Illnesses Examples: Anthrax, brucellosis. Infectious hepatitis, maligneat and benign moon, food poisoning, bisto* pltlmosis, cocridioidoayessis, etc. RECORDABLE OCCUPATIONAL INJURIES AND ILLNESSES are any occupational injuries or ill nesses which result in: 1) FATALITIES, regardless of the time between the bjary usd 'death, or the length si the Alness; or 2) LOST WORKDAYS CASES, other then faCtlilfcn'thit ' rani! In lost workdays; or 3) NONFATAL CASES WITHOUT LOST WORKDAYS, which mob In transfer to another job or terrainilloo or employment, or require medical treatment (as defined below), or ferolvo lost of cossrionssea# or restrictlea ol workor motion. This category also includes any disposed - --occupaileail illnesses which are reported to tba-ea? ployer bot are not classified as fatalities or last workday MEDICAL TREATMENT includes treatment administered by physician or by registered professional penoanri under the (tending order* of physician. Medical treatment does NOT include first aid treatment (one-time treatment and sub sequent observation of minor scratches, cob; burnt, splinters, and to forth, which do not ordinarily require medical care) even though provided by a physician or registered professional personnel. ESTABLISHMENT: A single physical location where bosh net* is conducted or where services or industrial operations are performed. (For example: a factory, tain, (tore, hotel, restaerae), mori* theater, farm, ranch, bank, sales office, ware house, or central administrative office.) Where dnliaelly Kparste activities see performed al a single physical location (such *s contract cotisiraerioa activities opented (tom tbs ame physical location as lumber yard), each activity shall be treated ax a septate establishment, * For firms engaged la activities such as sericulture, canstruct!**, transportation, communications, and electric, gas and sanitary serriees,,which may be physically dispersed, records may be-maintained at a place to which employee* report urit day. Records hr personae) who da not primarily report or work at a single esublithment. such as traveling talesmen, teehniefans, engineers, etc* shall he maintained at the location (rota which they are paid or the base from which personnel operate to cany out their activities. * WORK ENVIRONMENT Is comprised ol the physical loca tion. equipment, materials processed or used, and the beds of operations performed by an employee la the performance of his work, whether on or off the employer's premises. LOG OF"OCCUPATIONAL INIURIES AND ILLNESSES Each recordable ocenpational injury and occupational Uinta* must he entered on n log ol eases (OSHA Fern No. 100) with in two working days of receiving informatics that a recordable ease hi* occurred. Logs must he kept esmsl and retained for five (5) yean following the end of the calendar year to which they relate. Lop are to he maintained for three purpose*: 1) Lap for the prior five (S) year period must be available in the >iMt.s.m>^ without delay and at reasonable limes for examination by representative* el the Department of Labor or the Department of Health, Education and Wellare, ex Statea accorded Jurisdiction under the Act. 2) The fog will be used In preparing the annua] mnunary cf Occupations! Injuries and 1Haesses (OSHA Form No. 102) which must ha posted In every establishment. 3) Those establishments selected to participate In a statisdcal program trill be required to prepare a report based oa entries la this Jog la addition, the log will aid you in reviewing the occupation, al Injury tad Ufaess experience of year employees. INSTRUCTIONS FOR COMPLETING LOG OF OCCUPATIONAL INJURIES AND ILLNESS (OSHA Form No. 100) N Column 1 - CASE J)R FILE NUMBER (Onf*') Any numbernay be entered which will fadBiate comparison with supplementary records. . Column 2 - DATE OF INJURY OR ILLNESS For occupational Injuries enter the dato ef the work accident which resulted In Injury. For occupational Ilfaesaea eater tEe date of Initial diagnosis of lUnfaa, or, if absence occurred before diagnosis, the first day of the absence la connection wtih which the ease was diagnosed. Column 3 - EMPLOYEE'S NAME Column 4 OCCUPATION Eater the occupational tide of the job to which the em ployee was assigned at the time ol injury or Dina*, la the absence ol a ferma] oceupatioaa) title, enter a brief deserip. lion of the dutk* of the employee. Column S DEPARTMENT Ester the name of the department to which employee we* assigned at the lime of injury or illness, whether or not em ployee waa actually working fit that department at the time. In the absence ol forma! department titles, enter a brief description of normal workplace to which employee fa assigned. Column 6 NATURE OF INJURY OR ILLNESS AND PART(S) OF BODY AFFECTED Enter a brief description at the Injoiy or Qtnesa tad Indicate the part nr parts of body affected. Where entire body fa affected, the entry "body** an be used. Column 7 INJURY OR ILLNESS CODE Euler the one code which most accurately describe* the nature ol injury or 1Ueess. A Its: ol codes appears at tbc bottom el the log. A more complete description ef occupa tional Injuria sad illaesses appears below la "definitions." Column 8-FATALITIES If the occupational Injury ar nines* resulted ia death, cater date of death. , Column 9 LOST WORKDAYS Enter tbe namber ol days the employee would hare worked hat could not because of occupations] lajury ar Hints*. The number of lost workdays should not Inriade the day al Injury. The numberel days Includes allday* feoaseesrireernot) oa which, beta* af the injury or Blness: 1) the employee would have workedJot couldtsog or 2) the employee was assigntd to a temporary job, or 3) the employee worked at a pemanent fob leas than full time, er 4) the employee worked at a permanently assigned jab hut could not perform all duties narmafly assigned to it. For employees not having a regularly scheduled shift, Lc. certain truck drivers, cosstruotfea workers, farm labor, casual labor, part-time employee*, ete, it may be necessary to estimate the number of lost workdays. Estimate* of lest workdays ahaU be based oa prior wptk,Jritwry of the em ployee AND days worked by employees,'not"Cl or Injured, working la the depanmeat and/or occupation of the DI or . Injured employee. ' Column 10 - PERMANENT TRANSFER TO AN OTHER JOB OR TERMINATION OFEMPLOY MENT AFTER LOST-WORKDAYS '" Complete only If the employee did net return to hfa pterions assignment alter lost workdays. . Column 11 - NONFATAL CASES WITHOUT LOST WORKDAYS * ,. Eater a cheek b Column 1! for all Wee of ocenpational' Injury or U2neaa,^hlch,dld Aot hvo1re;fatilides or lost-- " watkday* Eil'Ed resall in: ' . m ---Transfer ta another job or termiaatioa of eapfeymeafe or __ --Medical treatment, other than first aid. or r ,, --Dtagsosit of occupational [Anar, er . --Loss ef ceasdoosnesa, ot " ' --Restriction of work ermstion, mler a cheek fa Column IL Column 12 - TRANSFER TO ANOTHER JOB Oft', TERMINATION OF EMPLOYMENT WITHOUT LOST WORKDAYS If the cheek la Colornn H represented a transfer "to another job or termination al employment with no Wit workdays, enter another cheek la Cobma 12. ^ INITIALING REQUIREMENT ' * - Each line entry regarding an ocenpational fajsry or flbutsv MUST BE INITIALED la the right hand margin by the person responsible for the accuracy of tbe entry. Changes _ fa aa catty also mast be Initialed fa the affected celatn. _ CHANGES IN EXTENT.OF OR OUTCOME OF INJURY OR ILLNESS ^ U there fa a change fa an occupationalTojury or Qbcas esse which affects entries ia. Columns 9, 10.11, er entry shoaM he Hoed oat and a new carry made. Far ex* topic. It an iajered employee it first required only medical treatment bat bier losl workdays, the check la <W*a Jl should be Lied out and the aeaber al last weekday* entered la another example, U aa employee with aa occupation^ illness last workdays, retimed to work, sad the* died of the Illness, the workdays noted U Colama 9 ihoaM he lined out and the date of death catered fa Column & An entry may be lined out it later found to he * non-/' occupational Injury or Ulaess. 249586 4)03534