OSHA职业安全与健康标准常用表格

OSHA's Form 301Year 年Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes.本表包含与员工健康有关的信息,必须采用合适的方式最大程度地保护员工的隐私,本信息仅用于职业健康与安全场合;LOGOInjuries and Illnesses Incident Report 伤害和疾病事故报告This Injury and Illness Incident Report is one of the first forms you must fill out when a recordable work-related injury or illness has occurred. Together with the Log of Work-Related injuries and Illnesses and the accompanying Summary, these forms help the employer and OSHA develop a picture of the extent and severity of work-related incidents. 当发生与工作有关的伤害和疾病时,伤害和疾病事故报告是第一个必须填写的表格;和日志及汇总表一起,这些表格有助于业主和OSHA 对事故程度和严重性的理解; Information about the employee 员工信息Information about the case 事件信息10) Case number from the Log 日志中的本事件编号 (Transfer the case number from the Log after you record the case.)在日志中记录事件后将事件序号转到此表1) Full Name 全名11) Date of injury or illness 伤害或疾病日期2) Street 街道12) ime employee began work 员工开始工作的时间AM/PMCity 城市State 国家 Zip 邮编13) Time of eventCheck if time cannot be determined 事件发生时间AM/PM □如时间不确定勾选此处Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out this form or an equivalent. Some state workers' compensation, insurance, or other reports may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the information asked for on this form.在收到可记录的已发生的与工作有关的伤害和疾病信息后的七日内,必须填写此表或类似表格,有些国家工人的工伤、保险或其他报告可能是可接受的,为了表格等效,任何替代品必须包含本表要求的所有信息;3) Date of birth 出生日期4) Date hired 雇佣日期 What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry."事故发生前员工正在做什么工作?描述活动,以及员工正在使用的工具,设备和材料;具体点:例如,“搬运屋面材料爬梯子”，“用手动喷雾器喷洒氯”，“日常计算机键入”5) □Male 男□Female 女Information about the physician or other health care professional医生和其他健康保健人员的信息What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement"; "Worker developed soreness in wrist over time."发生了什么？伤害是怎么发生的，如:"当梯子在湿地板上滑倒时，工人摔倒20英尽","工人在更换垫片时垫片爆破被氯喷射","工人加班手腕酸疼"According to Public Law 91-596 and 29 CFR 1904, OSHA's recordkeeping rule, you must keep this form on file for 5 years following the year to which it pertains 根据OSHA 的记录规则,本表必须保持5年 6) Name of physician or other health care professional 医生和其他健康保健人员的姓名7) If treatment was given away from the worksite, where was it given? 在离开工作场所之前进行了什么处理?If you need additional copies of this form, you may photocopy and use as many as you need.如果需要本表的副本,尽管复印和使用; Facility 设施 What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than "hurt", "pain", or "sore." Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."什么样的伤害或疾病?说出受影响的身体部位及如何受影响的;比“伤害”,“痛苦”,或“痛”更具体些;如:“紧张”、“化学烧伤,手”;“腕管综合症”;Street 街道City 城市State 国家 Zip 邮编Completed by 编制 8) Was employee treated in an emergency room?员工在急诊室接受治疗吗?What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank.什么物体或物质直接伤害员工的?如:“混凝土楼板”;“氯”;“摇臂锯;“如果这个问题不适用于这一事件,空白不填写;□Yes 是□No 否 Title 头衔9) Was employee hospitalized overnight as an in-patient?员工昨晚被当作一个病人住院了吗?Phone 电话Date 日期□Yes 是□No 否If the employee died, when did death occur? Date of death 如果员工死亡,死亡是什么时候发生的?死亡日期。

Page 1 of 1OSHA's Form 300Year 年Attention: This form contains information relating to employee health and must be used in a manner thatprotects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes.本表包含与员工健康有关的信息,必须采用合适的方式最大程度地保护员工的隐私,本信息仅用于职业健康与安全场合;LOGOLog of Work-Related Injuries and Illnesses 与工作有关的伤害和疾病记录You must record information about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must complete an injury and illness incident report (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you're not sure whether a case is recordable, call your local OSHA office for help.必须记录每一个与工作有关的伤害和疾病的信息,包括意识丧失,工作限制和调换,未工作天数,急救之外的医疗处理;必须记录医师和有资格健康保健专业人员诊断出的重要的与工作有关的伤害和疾病;还必须记录标准中所列的与工作有关的伤害和疾病的专项记录;需要的话,单个事件可以填写2行;对本表所亡的每一个伤害和疾病必须完成一个伤害和疾病报告(OSHA 表301)或等效表格;如果不确定是否需要记录,打电话给当地Establishment name公司名称City 城市State 国家OSHA's Form 300AYear年LOGO Summary of Work-Related Injuries and Illnesses与工作有关的伤害和疾病汇总(All establishments covered by Part 1904 must complete this Summary page, even if no injuries or illnesses occurred during the year.Remember to review the Log to verify that the entires are completed and accurate before completing this summary) 联邦法规第29卷1904部分所包含的所有公司即使在该年度没有发生任何职业伤害和职业病，都必须完成这页汇总表。