Cal/OSHA Form 301
Client Admin ▸ Safety ▸ Fresno Distribution Center ▸ Case 1
Completed 2026-09-16
Cal/OSHA Form 301
Injury and Illness Incident Report — California (Title 8)
Kept under 8 CCR § 14300 (California Code of Regulations, Title 8) · Cal/OSHA
Case no.: 1
Establishment: Fresno Distribution Center
Company: Acme Manufacturing
Log year: 2026
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.
1 · Information about the employee
Full name
Dana Ruiz
Job title
Forklift operator
Home address
418 Mariposa St, Fresno, CA 93721
Gender
Female
Date of birth
1988-04-02
Date hired
2022-06-13
2 · Information about the physician or other health-care professional
Name of physician or other health-care professional
Dr. H. Okonkwo
Facility, if treated away from the worksite
Valley Occupational Health
Facility address
—
Emergency room · hospitalised overnight
No · No
3 · Information about the case
Date of injury or onset of illness
2026-03-14
Where the event occurred
Loading dock, Bay 3
Time employee began work
7:00 AM
Time of event
2:30 PM
What was the employee doing just before the incident occurred?
Unloading cartons from a pallet at floor level
What happened?
Lifted a 60 lb carton and felt a sharp pain in the lower back
What was the injury or illness?
Lumbar strain
What object or substance directly harmed the employee?
60 lb carton
If the employee died, date of death
—
Completed by
Name
M. Okafor
Title
Safety Manager
Phone · date
(559) 555-0133 · 2026-09-16
This report is an internal record. It is not posted, and unlike the 300A it is not certified.