BWC Div. of Safety & Hygiene Semi-Annual Report

Fields marked with an * are required.

Contact Information

Report Period *

Employer Name *

Employer Address *

Employer City *

Employer State *

Employer Zip *

Employer Phone *

Employer Fax *

Name of Person Submitting Form *

Title of Person Submitting Form *

Date *

Email Address *

Date of Most Recent Injury or Illness Resulting in Day(s) Away from Work *

Report Information
Report all information below for CURRENT SIX MONTH PERIOD ONLY (corresponding with period identified above).

Average Number of Employees *

Total Hours Worked (Entire Six Month Period for All Employees) *

Recordkeeping Requirements
The following items are based on the Recordkeeping Requirements under the Occupational Safety & Health Act of 1970. The columns listed below correspond to the columns in the OSHA 300 Log and PERRP Form 300P.

Number of Deaths *

(Column G in OSHA 300 Log/PERRP Form 300P)

Number of Occupational Injuries and/or Illnesses Resulting in Days Away from Work *

(Column H in the OSHA 300 Log/PERRP Form 300P)

Number of Days Away from Work as a Result of Occupational Injuries and/or Illnesses *

(Column K in the OSHA 300 Log/PERRP Form 300P)

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.