Columbia Southern Widget Factor Safety Management System Paper Your boss just e-mailed you with a new project. He is requesting you review the information

Columbia Southern Widget Factor Safety Management System Paper Your boss just e-mailed you with a new project. He is requesting you review
the information for the CSU Widget Factory provided here. Upon opening the OSHA 300 log for CSU Widget Factory, you are to calculate
the total recordable incidence rate (TRIR), the DART rate, the lost workday
injury and illness rate (LWDII), and the severity rate (SR). Be sure to show
your calculations. Next, distinguish some of the leading indicators that you would use if
examining the CSU Widget Factor Safety Management System. Finally, summarize your findings back to your boss, including any
suggestions for improvement. Your paper must be a minimum of two pages. All sources, including the
textbook, must be cited/referenced in proper APA format. Note: You can type input into this form and save it.
Because the forms in this recordkeeping package are “fillable/writable”
PDF documents, you can type into the input form fields and
then save your inputs using the free Adobe PDF Reader. In addition,
the forms are programmed to auto-calculate as appropriate.
1
Jane Doe
Widget Welder
1
/
18
month / day
Reset
Reset
Reset
2
3
William Smith
Nellie Kershaw
Warehouse
Worker
Production
Line Worker
2
/
24
month / day
5
/
18
(I)
(J)
(K)
Burned Retinas – both eyes
●
2
days
days
●
Storeroom
Lumbar Strain
●
4
days
days
●
Main Production Floor
Respiratory Condition
●
2
month / day
/
/
month / day
Reset
/
month / day
Reset
/
month / day
Reset
/
month / day
Reset
/
month / day
Reset
(1)
Welding Area
month / day
Reset
(L)
/
Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review the
instructions, 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 displays a currently valid OMB control number. If you have any comments about these
estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room
N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.
0
3
0
0
days
days
days
days
days
days
days
days
days
days
days
days
days
days
8
14
Save Input
Add a Form Page
Page
1
of
1
(3)
(4)
(5)
(6)
●
days
2
0
Injury
Page totals
W
month / day
14
days
(2)
All other
illnesses
(H)
(1)
1
(2) (3)
0
0
0
All other
illnesses
(G)
Other recordable cases
On job
transfer or
restriction
Away
from
work
Hearing loss
Days away Job transfer
from work or restriction
Select the “Injury” column or
choose one type of illness:
(M)
Remained at Work
Death
Reset
Enter the number of
days the injured or
ill worker was:
Poisoning
SELECT ONLY ONE box for each case
based on the most serious outcome for
that case:
(E)
(F)
Where the event occurred
Describe injury or illness, parts of body
(e.g., Loading dock north end) affected, and object/substance that
directly injured or made person ill (e.g.,
Second degree burns on right forearm from
acetylene torch)
Hearing loss
Job title
(e.g., Welder)
AL
State
Poisoning
Employee’s name
(D)
Date of injury
or onset of
illness
(e.g., 2/10)
Orange Beach
Classify the case
Describe the case
(C)
City
Skin disorder
(B)
Establishment name
CSU Widget Factory
Respiratory
condition
(A)
Case
no.
U.S. Department of Labor
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
You must record information about every work-related death and 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 Part 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.
Identify the person
Year 20 15
Respiratory
condition
Log of Work-Related
Injuries and Illnesses
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.
Skin disorder
(Rev. 01/2004)
Injury
OSHA’s Form 300
(4)
(5)
(6)
OSHA’s Form 300A
(Rev. 01/2004)
Summary of Work-Related Injuries and Illnesses
Note: You can type input into this form and save it.
Because the forms in this recordkeeping package are “fillable/writable”
PDF documents, you can type into the input form fields and
then save your inputs using the free Adobe PDF Reader.
Year 20
U.S. Department of Labor
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
All establishments covered by Part 1904 must complete this Summary page, even if no work-related 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.”
Employees, former employees, and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access
to the OSHA Form 301 or its equivalent. See 29 CFR Part 1904.35, in OSHA’s recordkeeping rule, for further details on the access provisions for
these forms.
Establishment information
Your establishment name
Street
City
Number of Cases
Total number of
deaths
21982 University Lane
Orange Beach
State
AL
Zip
36561
Industry description (e.g., Manufacture of motor truck trailers)
Total number of
cases with days
away from work
0
Total number of cases
with job transfer or
restriction
3
(G)
CSU Widget Factory
Total number of
other recordable
cases
0
(H)
Widget Manufacturing
Standard Industrial Classification (SIC), if known (e.g., 3715)
0
(I)
(J)
OR
North American Industrial Classification (NAICS), if known (e.g., 336212)
Number of Days
326199
Total number of days
away from work
Total number of days of job
transfer or restriction
8
Employment information (If you don’t have these figures, see the
Worksheet on the next page to estimate.)
14
(K)
27
Annual average number of employees
(L)
Total hours worked by all employees last year
58675
Injury and Illness Types
Sign here
Total number of . . .
Knowingly falsifying this document may result in a fine.
(M)
(1)
Injuries
2
(4)
Poisonings
0
(2)
Skin disorders
0
(5)
Hearing loss
0
(3)
Respiratory conditions
1
All other illnesses
0
(6)
Post 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 50 minutes per response, including time to review the instructions, 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 displays a currently valid OMB control number. If you have any
comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW,
Washington, DC 20210. Do not send the completed forms to this office.
I certify that I have examined this document and that to the best of
my knowledge the entries are true, accurate, and complete.
________________________________
Company executive
Phone ______ – _______ – ___________
___________________
Title
Date _____ / _____ / ______
Save Input
OSHA’s Form 301
Note: You can type input into this form and save it.
Because the forms in this recordkeeping package are “fillable/writable”
PDF documents, you can type into the input form fields and
then save your inputs using the free Adobe PDF Reader. In addition,
the forms are programmed to auto-calculate as appropriate.
Injury and Illness
Incident Report
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.
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.
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.
If you need additional copies of this form, you
may photocopy the printout or insert additional form
pages in the PDF, and then use as many as you need.
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.
U.S. Department of Labor
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
Information about the employee
Information about the case
10) Case number from the Log
1) Full name
(Transfer the case number from the Log after you record the case.)
11) Date of injury or illness
2) Street
Month
Day
Year
12) Time employee began work
3) City
State
13) Time of event
4) Date of birth
Month
Day
Year
Month
Day
Year
AM
PM
PM
Check if time cannot be determined
14) 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.”
5) Date hired
Male
Female
AM
ZIP
Information about the physician or other health care
professional
15) 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.”
6) Name of physician or other health care professional
7) If treatment was given away from the worksite, where was it given?
16) 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.”
Facility
Street
City
State
̀ZIP
17) 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.
8) Was employee treated in an emergency room?
Yes
No
Completed by
Title
Phone
–
–
Date
Month
Day
Year
9) Was employee hospitalized overnight as an in-patient?
Yes
No
Page
1
of
1
18) If the employee died, when did death occur?
Date of death
Month
Save Input
Add a Form Page
Day
Year
Reset
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. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.

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