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0 . . ,—• ,. ., .._ ,.. <br /> • <br /> OSHA's Form 300A (Rev.01(2004) Note:Yon ean type input into this foam and save it. Year 20 /8 <br /> Because the forms in this recordkeeping package are'fdlabWvaitable' <br /> Summary of Work-Related Injuries and Illnesses Pen documents,i guts using type into free the Adobe PDF R form eeder. u s.Department of Labor <br /> then save your inputs the PDF Reader. amone 40 fa.qw dt..na aeaa ar tho <br /> y.'.••Form gpmvmj OMB so.121a017a <br /> Ail establishments covered by Part 1904 must complete this Summary page,even if no work-related Injuries or illnesses occurred during the year. <br /> Remember to review the Log to verify that the entries are Complete and accurate before completing this summary. <br /> 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 Establishment information <br /> every page of the Log.If you had no cases,write 0.' v„„, •., ,,,,,,,Elk River Municipal Utilities <br /> Employees,former employees.and thelrepresentatives have the right to review the OSHA Fonn 300 in its entirety.They also have limited access <br /> to the OSHA Form 301 or its equivalent See 29 CFR Part 1904.35,in OSHA's recordkeeping rude,for further details on the access provisions for street 13069 Orono Pkwy <br /> these roans. <br /> CityElk River stag MN yip 55330 <br /> Number of Cases <br /> Industry description(e.g..Mamfactare of motor truck trailers) <br /> Total number of Total number of Total number of cases Total number of Electric&Water Utilities <br /> deaths cases with days with job transfer or other recordable ' <br /> away from work restriction cases Standard Industrial Classification(SIC),if known(e.g.,3715) <br /> 0 0 0 1 9924 <br /> (0) (it) (If WIOR <br /> North American Industrial Classification(NAICS),if known(e.g.,336212) <br /> Number of Days 922190 <br /> Total number of days Total number of days of job Employment information ahem don't have them figures.see the <br /> away from work transfer or restriction Workrhrer on the next page to estimate.) <br /> Annual average number of employees 44 <br /> (R) (L) <br /> 79436 <br /> Total hams worked by all employees last <br /> Injury and Illness Types Sign here <br /> Total number of... Knowingly falsifying this document may result in a fine. <br /> (M) <br /> (t l Injuries 1 (4)Poisonings 0 I certify that I have examined this document and that to the best of <br /> my Itpowledge the a re true,ap/curaattee,,�my complete. /�v,/i(�y- <br /> (2)Skin disorders 0 (5)Hearing loss 0 C—','�r . LIA a r/�' Of&- "p- <br /> (3)Respiratory conditions 0 (6)All other illnesses 0 CAP //eaecunve -��t Tian �/�� n <br /> - Phone'W H�/1- 2-020 Date / l �II/ 2.011 <br /> Past this Summary page from February t to Apn s 30 at the year following the year covered by the teem _^ Ye4npVt <br /> ?Olio reportin.endT hmeu r«aba menu of enaoo.Rawlo umw..voKwmiw.d amm+oo^-f including hs it disays a000i onol,O control <br /> ar..ce4ne .c:.a„ <br /> 'ended about nthnuff eteCe or of myobaasm.rmem re collodot iredon,so ce o:USpond ep cellrtment ofIe ivf 6m vdw S euply.,onmey vond saco,wl Coo utionA if you msmr• <br /> aMoa 021G,estimates ormyNhmaryshoses se as office.o,cello:VS Deportment oEL.bm,OSHA O&rs.r3ttle:._,AnJ.ri;Ro®t1.3aJ1.2na Constitution A.�a.NW, <br /> Wmaiatma DC 2a21 a,Do not mad the completed foams so this office. <br /> 67 <br />