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Date of death+-AM/PM *Was employee treated in an emergency room?5Was employee hospitalized overnight as an in-patient?a If you need additional copies of this form, you may photocopy and use as many as you need.B(Transfer the case number from the Log after you record the case.)"Check if time cannot be determined.Summary of Work-Related Injuries and Illnesses"Date of injury or onset of illness-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.">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.6 (mo./day)%On job transfer or restriction (days)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.  Hearing LossQCHECK ONLY ONE box for each case based on the most serious outcome for that case:(6)Away From Work (days)(6) All Other Illnesses(5) Hearing LossINorth American Industrial Classification (NAICS), if known (e.g., 336212)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."*14)*15) *16) *17) *Please do not include any personally identifiable information (PII) pertaining to worker(s) involved in the incident (e.g., no names, phone numbers, or SSNs) in the following fields.What was the injury or illness? Tell us the part of the body that was affected and how it was affected. Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."County:Other:State: Public Employer: N.J. Department of Labor &! Workforce Development2 Public Employees Occupational Safety & Health NJOSH - 300A )Public Employer Management RepresentativeDIndustry description (e.g., Police, DPW, Sewerage Treatment, School)Department or AgencyPublic Employer Year: ______NJOSH Form-300-Public Employees Occupational Safety & Health N.J. DOL & WDNJOSH Form 301r 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.]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 PEOSH develop a picture of the extent and severity of work-related incidents. 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.)Employers, former employees and their representatives have the right to review the NJOSH Form 300 in its entirety. They also have limited access to the NJOSH Form 301 or its equivalent. See 29 CFR 1904.35, in OSHA's Recordkeeping rule, for further details on the access provisions for these forms.fPost this Summary page from February 1 to April 30 of the year following the year covered by the form.Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review the instruction, search and gather the data needed, and complete and review the collection of information. Questions regarding this form should be directed to the Office of Public Employees Occupational Safety and Health, ӣƵ Department of Labor and Workforce Development, PO Box 386, Trenton, ӣƵ 08625. Do not send the completed forms to this office.9You 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 the Office of Public Employees Occupational Safety and Health for help.-Public reporting burden for this collection of information is estimated to average 50 minutes per response, including time to review the instruction, search and gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it disp<plays a currently valid OMB control number. Comments regarding this form should be sent to the Office of Public Employees Occupational Safety and Health, NJ Department of Labor and Workforce Development, PO Box 386, Trenton, NJ 08625.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 entries are complete and accurate before completing this summary.Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you've added the entries from every page of the log. If you had no cases write "0."Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number. 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