OSHA's Form 301
Client Admin ▸ Safety ▸ Amarillo Yard ▸ Case 9
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OSHA's Form 301
Injury and Illness Incident Report
Kept under 29 CFR Part 1904 · Federal OSHA
Case no.: 9
Establishment: Amarillo Yard
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
Electrician
Home address
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Gender
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Date of birth
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Date hired
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2 · Information about the physician or other health-care professional
Name of physician or other health-care professional
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Facility, if treated away from the worksite
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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
2026-09-21
Where the event occurred
North stairwell, 3rd floor
Time employee began work
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Time of event
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What was the employee doing just before the incident occurred?
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What happened?
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What was the injury or illness?
Slipped on wet decking coming down the stairs and landed on his left wrist.
What object or substance directly harmed the employee?
—
If the employee died, date of death
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Completed by
Name
—
Title
—
Phone · date
—
This report is an internal record. It is not posted, and unlike the 300A it is not certified.