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OSHA's Form 300A (Rev. 04/2004) Note: You can type input into this form and save it <br />Because the forms in this recordkeeping package are'fillableNvntable" <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. <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 />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 />0 0 0 1 <br />(G) (H) (1) (J) <br />Number of Days <br />'total number of days Total number of days of <br />awav from workjob transfer or restriction <br />n n <br />(K) (L) <br />Total number of... <br />(M) <br />(1) Injuries 1 <br />(2) Skin disorders 0 <br />(3) Respiratory conditions 0 <br />(4) Poisonings 0 <br />(5) hearing loss 0 <br />(6) All other illnesses 0 <br />Post this Summary page from February t to April 30 of the year following the year covered by the form <br />fimbl'me reportioy bmdrn (ar d,is collcetiou of iNawation is estimmed w avenge SN mmuws per yunae_ mnclndmg time w rrrew dk v�svvetivru, zemeh and Barber tM1e dam ne�hd oM <br />mplete adreview. Nc wllarioaofinformation. Pmseas nre mtrequiredwrespondtothe mllecaonorinf OSHA OSHA Ounless fSwfeveaewmmly r7lid OMncanvol number. lfsou haee auy <br />rs abom thug omhcrnzpmsofJmis dma mllee wmam:[IS Depsmment aflabvr. llice ofSwasa<al Analysu. Room N-3631. 2rmm Counnnien Awenve.NW. <br />washi, n DC 2t121n. Do mt sad a, completed forms ro this ff.. oa <br />Year 20 99 <br />U.S. Department of Labor <br />Form approved OMB ao. 121-1l6 <br />Estabfishment information <br />Elk River Municpal Utilities <br />Street 13069 Orono Parkway <br />cm Elk River state MN Zip 55330 <br />Industry description (e.g- Man f crurc of motor tuck waiters) <br />Municipal utility - electric and water <br />North American Industrial Classification (NAICS), ifknown (e.g., 336212) <br />221122 <br />Employment information pfyou don't hose these figurer, see Inc <br />Workslaeet on the ,test page to estfmate.J <br />Annual average number ofemployees 47 <br />Total hours worked by all employees last Year 84,585.68 <br />Sign here <br />Knowingly falsifying this document may result in a fine. <br />I cenifv that I have examined is document and that to the best of <br />my k led,P\fire ertm.es aCetrue, accurate, and compl:etef.J <br />Company executive Title <br />Phone(763) 441-2020 Dats01/27/2023 <br />Reset <br />