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CASC Semi-Annual Report

Form Instructions

The top portion of the form is self-explanatory. The person completing the semi-annual report should fill in the "Submitted by" information.

(1) Date of Most Recent Lost-Time Injury or Illness
This is the date of the most recent injury that resulted in an employee missing at least one full day of work. That date does not necessarily have to be during this period. The word "None" cannot be used. There must be a date identified. If no injuries have ever occurred, you should report the last day of the year prior to the year the business opened (i.e. a business opened 6/1/2000, no injuries, the default date would be 12/31/1999).

(2) and (3) Average Number of Employees/Total Hours Worked
Multiply the average number of employees x the average number of hours worked per week x the number of weeks in the six-month period. (i.e. 725 employees x 40 hours = 29,000 hours x 26 weeks in the six month period = 754,000 hours)

(4) Deaths
Taken from OSHA 300 Log column G, the number of deaths that resulted from an occupational accident during this six-month period.

(5) Number of Injuries/Number of Workdays Lost
Taken from OSHA 300 Log column H, the number of occupational injuries or illnesses resulting in days away from work.

(6) Number of Workdays Lost
Taken from OSHA 300 Log column K, the total number of days away from work as a result of occupational accidents during the six-month period. NOTE: If the days away from work resulted from an accident which occurred in a previous six-month period, please send an updated form for that period, adding on the additional workdays lost.

IMPORTANT:
If the date of last injury or illness resulting in days away from work (1) was during the current six month period you are reporting on, there should at least be a 1 for (5) the number of injuries or illnesses, and (6) the number of days away from work.

If the date of last injury or illness resulting in days away from work was during a previous six-month period, (5) and (6) should be 0.

Co-sponsored by BWC's Division of Safety and Hygiene
SEMI-ANNUAL REPORT


Time Period:	This report is for period: January 1 — June 30 This report is for period: July 1 — December 31


Company:

Address:

City:		State:	Zip:


Telephone:

Fax:


Submitted By:



1)	Date of most recent injury or illness resulting in day(s) away from work (mm/dd/yyyy)
Report all information below for the current six month period.

2)	Average number of employees

3)	Total hours worked (entire six month period, all employees)
Items 4, 5 and 6 are based on the Recordkeeping Requirements under the Occupational Safety & Health Act of 1970 (rev. 1/1/02). The columns listed below correspond to the columns in the OSHA 300 Log.

4)	Number of deaths (column G in OSHA 300 Log)

5)	Number of occupational injuries and/or illnesses resulting in days away from work (column H in the OSHA 300 Log)

6)	Number of days away from work as a result of occupational injuries and/or illnesses (column K in the OSHA 300 Log)
Note: If you report a death, injury or illness resulting in days away from work in the current six month period (item 4 or 5), the most recent date of death, injury or illness must correspond with item 1.


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