STARK COUNTY SAFETY COUNCIL

Co-sponsored by BWC’s Division of Safety and Hygiene

 

 

 

Semi-Annual Report is due by July 15

(For current period January 1 - June 30, 2009)

 

Please submit form online below or download pdf file and mail to:

 

Stark County Safety Council

Attn: Connie Cerny

222 Market Ave N

Canton, OH  44702

Phone: 330-458-2061  Fax: 330-489-6012

 

Safety Council Account Number

 

Please provide the following contact information:

Company Name

Street Address
Address (cont.)
City
State
Zip Code
Phone
FAX
Submitted by

Is the information provided above new?

Yes No

1.) DATE OF MOST RECENT INJURY OR ILLNESS RESULTING IN DAY(S) AWAY FROM WORK (If there were not incidents in the current 6 month period this would be the same date as reported the last semi-annual report)

-- mm/dd/yy

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Report All Information Below For CURRENT SIX MONTH PERIOD ONLY (January 1 – June 30, 2009)

 

2.) Average Number of Employees

3.) Total Hours Worked (entire six month period, all employees)

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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.