Illness & Injury Report Form

Statistics are due 15 days after the end of each quarter: 4/15, 7/15, 10/15, 1/15.

Select the quarter	1st Quarter (Jan-Mar): submit by 4/15/xx 2nd Quarter (Apr-Jun): submit by 7/15/xx 3rd Quarter (Jul-Sep): submit by 10/15/xx 4th Quarter (Oct-Dec): submit by 1/15/xx
Company
Company Identifier or location number
Address
City
State
Zip
Phone
Fax
Email
Safety Rep
Title
Person filling out this form, if not the Safety Rep:
Type of Operation	Paper Mills ~ Large mills working over 2 million hours/year Paper Mills ~ Medium mills working between 1 & 2 million hours/year Paper Mills ~ Small mills working under 1 million hours/year Pulpmills Tissue Mills Bag Plants Sawmills Folding Cartons Woodlands ~ Large working over 200,000 hours/year Woodlands ~ Small working 200,000 hours/year or less Building Products Corrugated Plant Sheet Plant Tubes & Cores Recycle Collection 100% Recycle Mill Particle Board Specialty Operations Sheet Converting Other

Reporting period	Total Hours	Total Cases1	Lost Workday Cases2	Restricted Duty Cases3	Fatalities4
Quarter
Year
'Total cases' = Columns G + H + I + J from OSHA log. 'Lost Workday Cases' or 'Cases with Days Away from Work' = Column H of OSHA Log. 'Restricted Duty Cases' = Column I of OSHA Log. 'Fatalities' = Column G of OSHA Log.

The section is to be used ONLY to request awards for periods of accident-free work (also known as "no-lost-time" cases) or for other special recognition.

Approximate number of hours worked per year	Under 500,000 500,000 - 1,000,000 Over 1,000,000
Number of consecutive hours without an OSHA lost work day case with days away from work.
Period Began
Period Ended