Members, send to john_sunderland@bkitech,com or fax to 850-584-1220. Print your confirmation page and keep it for your records. Statistics are due 15 days after the end of each quarter: 4/15, 7/15, 10/15, 1/15. Top of Form | Select the quarter | 4th Quarter (Oct-Dec): submit by 1/15/xx2nd Quarter (Apr-Jun): submit by 7/15/xx1st Quarter (Jan-Mar): submit by 4/15/xx3rd Quarter (Jul-Sep): submit by 10/15/xx | | Company | | | Company Identifier or location number | | | Address | | | City | | | State or Province | | | Zip | | | Phone | | | Fax | | | Email | | | Safety Rep | | | Title | | | Person filling out this form, if not the Safety Rep: | | Type of Operation:
Select One OnlyPaper Mills ~ Large mills (working over 2 million hours/year)Paper Mills ~ Medium sized mills (working between 1 and 2 million hours/year)Paper Mills ~ Small mills (working under 1 million hours/year)Pulp MillsTissue MillsBag PlantsSawmillsFolding CartonsWoodlands ~ Large (over 200,000 work hours/year)Woodlands ~ Small (200,000 or LESS work hours/year)Building ProductsCorrugated PlantSheet PlantTubes & CoresRecycle Collection100% Recycle MillParticle BoardSpecialty OperationsSheet ConvertingOther | | | | Reporting period | Total Hours | Total Cases1 | Lost Workday Cases2 | Restricted Duty Cases3 | Fatalities4 | | This quarter only | | | | | | | Total: Year to Date | | | | | | 1 'Total cases' = Columns G + H + I + J from OSHA log.
2 'Lost Workday Cases' or 'Cases with Days Away from Work' = Column H of OSHA Log.
3 'Restricted Duty Cases' = Column I of OSHA Log.
4 'Fatalities' = Column G of OSHA Log. |
| Approximate number of hours worked per year: | Under 500,000500,000 to 1,000,000Over 1,000,000 | | Number of consecutive hours without an OSHA lost work day case with days away from work. | | Period began:
Enter starting date | | Period ends:
Enter ending date | |
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