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OSHA -is Form 300A (Rev. 04/2004) Note: You can type input into this form and save it. Year 20 <br />Because the forms in this recordkeeping package are "fillable/writable" 24 <br />PDF documents, you can type into the input form fields and 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 Health Adminiatratton <br />F.— approved OMB no. 121 M 176 <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 complefrng 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 Total number of <br />deaths cases with days <br />away from work <br />0 0 <br />(G) (H) <br />Total number of days <br />away from work <br />0 <br />(K) <br />Total number of cases Total number of <br />with job transfer or other recordable <br />restriction cases <br />0 2 <br />Total number of days of <br />job transfer or restriction <br />0 <br />(L) <br />Total number of... <br />(M) <br />(1) Injuries 1 (4) Poisonings 0 <br />(2) Skin disorders 0 (5) Hearing loss 1 <br />(3) Respiratory conditions 0 (6) All other illnesses 0 <br />W) <br />Post this Summary page from February Ito Apr1130 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 rexim the instructions- search and gather the dam needed, and <br />complete and redmv the collection of information. Persons arc not required to respond to the collection of information unless it displays a current, valid OMB central number, if you heoe am_ - <br />comments about these estimates or any other aspects of this data collection_ contact: US Depamneat of Labor. OSHA Office of Statistical Analysis, Room N-3644_ 200 Constitution Avenue. NW. <br />Washington. DC 20210_ Do not scud the completed forms to this office_ <br />Establishment information <br />Yourestablishmentname Elk River Municipal Utilities <br />street 13069 Orono Parkway <br />Cin,Elk River state MN Zip 55330 <br />Industry description (e.g., Manufacture of motor track trailers) <br />Municipal Utility - Electric and Water <br />North American Industrial Classification (NAICS), if known (e.g., 336212) <br />221122 <br />Employment information (!f you don't have these figures, see the <br />Worksheei on the next page to estimate) <br />Annual average number of employees 45 <br />Total hours worked by all employees last year 81,896.59 <br />Sign here <br />Knowingly falsifying this document may result in a fine. <br />I ccrtify that I have examined this document and that to the best of <br />my kno vledge tries az e, accurate, and complete. <br />17 <br />Company executive �Title <br />Phone(763) 441-2020 Date January 31, 2025 <br />Reset <br />62 <br />