Cal/OSHA Form 301
Client Admin ▸ Safety ▸ Fresno Distribution Center ▸ Case 4
Not started
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.: 4
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
Priya Nandakumar
Job title
Picker
Home address
—
Gender
—
Date of birth
—
Date hired
—
2 · Information about the physician or other health-care professional
Name of physician or other health-care professional
—
Facility, if treated away from the worksite
—
Facility address
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Emergency room · hospitalised overnight
Not answered · Not answered
3 · Information about the case
Date of injury or onset of illness
2026-07-08
Where the event occurred
Aisle 2
Time employee began work
—
Time of event
—
What was the employee doing just before the incident occurred?
—
What happened?
—
What was the injury or illness?
Minor abrasion to left hand; cleaned and bandaged on site
What object or substance directly harmed the employee?
—
If the employee died, date of death
—
Completed by
Name
—
Title
—
Phone · date
—
This report is an internal record. It is not posted, and unlike the 300A it is not certified.