Company Name*Size CategoryAddress* Street Address Address Line 2 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxEmail* Contact Person***THE INFORMATION YOU RECORD ON THIS SHEET WILL BE KEPT STRICTLY CONFIDENTIAL**1: Number of Work Hours for 2019*Record only those hours worked by your company's jobsite craft labor2: Number of Fatalities 2019:*Record all work related jobsite craft labor fatalities (Column G of OSHA Form 300A)3: Number of OSHA Recordable Injuries in 2019:*Number of jobsite craft labor injuries (Total of Columns G, H, I, & J of OSHA Form 300A)4: Number of Lost Workday Cases in 2019:*Number of jobsite craft labor Lost Workday Cases (Column H of OSHA Form 300A)5: Number of Lost Workdays in 2019:*Total number of Lost Workdays resulting from the Lost Workday Cases (Column K of OSHA Form 300A)Fatality Incidence RateOSHA Recordable Injuries Incidence RateLost Workday Cases Incidence RateLost Workdays Incidence RateEmailThis field is for validation purposes and should be left unchanged.
