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HAs Form 300A (Rev. 0412004) Note: You can type input into this form and save it. Y@ciC 2O Because the forms in this recordkeeping package are "fi Ila ble/writable" 21 <br />PDF documents, you can type into the input form fields and — <br />Summary of Work -Related Injuries and Illnesses then save your inputs using the free Adobe PDF Reader. U.S. Department of Labor <br />Occupational Safety and Hearth Administration <br />Form enoroved OMR ne 191 R-0176 <br />All 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 <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 />Total number of <br />Total number of <br />Total number of cases <br />Total number of <br />deaths <br />cases with days <br />with job transfer or <br />other recordable <br />away from work <br />restriction <br />cases <br />0 <br />0 <br />1 <br />1 <br />(G) <br />(H) <br />(I) <br />(d) <br />NumberofDays <br />Total number of days <br />Total number of days of <br />away from work <br />job transfer or restriction <br />0 <br />30 <br />(K) <br />(L) <br />Injury and Illness <br />Total number of... <br />Types <br />(M) <br />(1) Injuries <br />2 <br />(4) Poisonings <br />0 <br />(2) Skin disorders <br />0 <br />(5) Hearing loss <br />0 <br />(3) Respiratory conditions 0 <br />(6) All other illnesses <br />0 <br />Post this Summary page 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 review the instructions, search and gather the dataneeded, 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. [f you have any <br />comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitmion Avenue, Nw, <br />washington, DC 20210. Do not send the completed forms to this office. <br />59 <br />Establishment information <br />Yourestabltahmentname Elk River Municipal Utilities <br />street 13069 Orono Parkway <br />City Elk River state MN Zip 55330 <br />Industry description (e.g., Manufacture of motor truck trailers) <br />Municipal Utility - Electric and Water <br />North American Industrial Classification (NAICS), if known (e.g., 336212) <br />2 2 1 1 2 2 <br />Employment information (If you don't have these figures, see the <br />Worksheet on the next page to estimate.) <br />Annual average number of employees 45 <br />Total hours worked by all employees last year 84,317.00 <br />Sign here <br />Knowingly falsifying this document may result in a fine. <br />I certify that I have examined this document and that to the best of <br />my knowledge the ntries are true, accurate, and complete. <br />Comp executive Title <br />Phone 763-441-2020 Date / 28 2dZZ <br />Reset <br />Y" <br />