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OSHA's Form 300A (Rev.0412004) <br />Summary of Work -Related Injuries and Illnesses <br />O- <br />Note: You can type input into this form and save it <br />Year 20 <br />Because the forms in this recordkeeping package are "fillable/writable" <br />22 <br />PDF documents, you can type into the input form fields and <br />U.S. Department of Labor <br />then save your inputs using the free Adobe PDF Reader_ <br />oeevpano,,,r snrery atia rroann aatnrntsarauon <br />Form approved OMB no. 1218-01 76 <br />All establishments covered by Part 1904 must complete this Summarypage, 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 <br />every page of the Log. If you had no cases, write "0." <br />Employees, former employees, and their representatives have the right to review the OSHA Form 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 rule, for further details on the access provisions for <br />these forms. <br />NumberofCases <br />Total number of Total number of Total number of cases Total number of <br />deaths cases with days with job transfer or other recordable <br />away from work restriction cases <br />(G) (H) <br />Number of Days <br />Total number of days Total number of days of <br />away from work- job transfer or restriction <br />I <br />(K) <br />(L) <br />I <br />Injury and Illness Types <br />Total number of . _ . <br />(M) <br />(1) Injuries 1 (4) Poisonings 0 <br />(2) Skin disorders 0 (5) Hearing loss 0 <br />(3) Respiratory conditions 0 (6) All other illnesses 0 <br />(d) <br />Post this Summarypage from February 1 to April 30 of the year following the year covered by the form. <br />Public reporting burden for this collection of information is estimated to average 58 minutes per response including time to renew the instructions, search and gather the data needed, and <br />complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any <br />comments about these estimates or any other aspects ofthis data collection. contact: US Department of Labor. OSHA Office of Statistical Analysis_ Room N-3644. 200 Constitution Avenue. NW_ <br />Washington. DC 20210. Do not send the completed forms to this office. <br />Establishment information <br />Yeuresrbtrsh,umn amn Elk River Municpal Utilities <br />street 13069 Orono Parkway <br />city Elk River State MN Zip 55330 <br />Industry description (e.g., Manufacture ofmotor truck trailers) <br />Municipal utility - electric and water <br />North American Industrial Classification (NAICS),ifknown (e.g., 336212) <br />221122 <br />Employment information (Ifyou don't have these figures, see the <br />Worksheet on the nest page to estimate) <br />Annual average number of employees 47 <br />Total hours worked by all employees lastyear 84,585.68 <br />Sign here <br />Knowingly falsifying this document may result in a fine. <br />I certify that I have examined,is document and that to the best of <br />my k ledge.the e5tries ace' true, accurate, and complete. <br />Company executive Title <br />Phone(763) 441-2020 Date 0 1 /27/2023 <br />Reset <br />M] <br />