SUMMIT COUNTY  SAFETY COUNCIL

Co-sponsored by BWC’s Division of Safety and Hygiene

 

Semi-Annual Report

1st [ x ] due by July 15                                                                     2nd [  ] due by January 15

  (for current period January 1 – June 30, 2008)                                 (for current period July 1 – December 31, 2008)

 

 Safety Council Account Number  ________________  /  ___  ___  /  ___  ___  /  ___  ___

 

      Company Name ________________________  Phone __________________________________

      Address ______________________________  Fax ____________________________________

      City / State / Zip ________________________

      Submitted By __________________________  Date ___________________________________

        Please check here if information provided above has been updated on this report.

1.)  DATE OF MOST RECENT INJURY OR ILLNESS RESULTING IN DAY(S) AWAY FROM WORK

 

______   /   ______   /   ______

Month              Day               Year

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Report All Information Below For CURRENT SIX MONTH PERIOD ONLY (corresponds with period identified above)

2.)  Average Number of Employees......................                                                     

 

3.)  Total Hours Worked (entire six month period, all employees)                          .......................................

***********************************************************************************************************

 

Items 4, 5 and 6 are based on the Recordkeeping Requirements under the Occupational Safety & Health Act of 1970

(rev. 1/1/02).  The columns listed below correspond to the columns in the OSHA 300 Log.

 

4.) Number of Deaths . . (column G in OSHA 300 Log)....                                

 

5.) Number of occupational injuries and/or illnesses resulting in days away from work

                        (column H in the OSHA 300 Log) ....                         

 

6.) Number of days away from work as a result of occupational injuries and/or illnesses

                        (column K in the OSHA 300 Log).....                        

 

           Note:  If you report a death, injury or illness resulting in days away from work in the current

six month period (item 4 or 5), the most recent date of death, injury or illness must correspond with item 1.

 

Please return this form to:

Summit County Safety Council

One Cascade Plaza 18th Floor

Akron, Ohio 44308

(330) 375-3185 phone / (330) 376-3852 fax

Revised 07/08