Southern Buckeye Safety Council
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EVENTS CALENDAR
Contact
Semi-Annual Report
You can complete the online form below or send your form by any of the methods listed on our
CONTACT
page.
Click
here
to download the instruction form.
*
Indicates required field
For what year are you reporting?
*
2018
2019
For which Half of the year are you reporting?
*
1st Half Due by July 15
2nd Half Due by January 15
BWC Policy Number
*
Company Name:
*
Street Address
*
City
*
State
*
Zip Code
*
Phone Number
*
Fax Number
*
Submitted By
*
*Name of Person Completing this Form
E-mail
*
Date:
*
Has information provided above been updated on this report?
*
Yes
No
1.) Date of MOST RECENT injury or illness resulting in day(s) away from work: (mm/dd/yyyy)
*
Report All Information Below For
CURRENT SIX MONTH PERIOD ONLY
(corresponds with period identified above)
2.) Average Number of Employees:
*
Additional Comments
*
3.) Total Hours Worked (entire six month period, all employees)
*
Additional Comments
*
Items 4, 5, & 6 are based on the Recordkeeping Requirements under the Occupational Safety & Health Act of 1970.
The questions listed below correspond to the columns in the OSHA 300 Log/PERRP Form 300P.
4.) Number of Deaths
*
* (column G in the OSHA 300 Log/PERRP Form 300P)
5.) Number of occupational injuries and/or illnesses resulting in days away from work
*
6.) Number of days away from work as a result of occupational injuries and/or illnesses
*
* (column K in the OSHA 300 Log/PERRP Form 300P)
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.
Submit
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