4.1a ERMUSR 02-14-2023OSHA's Form 300A (Rev.0412004)
Summary of Work -Related Injuries and Illnesses
O-
Note: You can type input into this form and save it
Year 20
Because the forms in this recordkeeping package are "fillable/writable"
22
PDF documents, you can type into the input form fields and
U.S. Department of Labor
then save your inputs using the free Adobe PDF Reader_
oeevpano,,,r snrery atia rroann aatnrntsarauon
Form approved OMB no. 1218-01 76
All establishments covered by Part 1904 must complete this Summarypage, even if no work -related injuries or illnesses occurred during the year.
Remember to review the Log to verify that the entries are complete and accurate before completing this summary.
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
every page of the Log. If you had no cases, write "0."
Employees, former employees, and their representatives have the right to review the OSHA Form 300 in its entirety They also have limited access
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
these forms.
NumberofCases
Total number of Total number of Total number of cases Total number of
deaths cases with days with job transfer or other recordable
away from work restriction cases
(G) (H)
Number of Days
Total number of days Total number of days of
away from work- job transfer or restriction
I
(K)
(L)
I
Injury and Illness Types
Total number of . _ .
(M)
(1) Injuries 1 (4) Poisonings 0
(2) Skin disorders 0 (5) Hearing loss 0
(3) Respiratory conditions 0 (6) All other illnesses 0
(d)
Post this Summarypage from February 1 to April 30 of the year following the year covered by the form.
Public reporting burden for this collection of information is estimated to average 58 minutes per response including time to renew the instructions, search and gather the data needed, and
complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any
comments about these estimates or any other aspects ofthis data collection. contact: US Department of Labor. OSHA Office of Statistical Analysis_ Room N-3644. 200 Constitution Avenue. NW_
Washington. DC 20210. Do not send the completed forms to this office.
Establishment information
Yeuresrbtrsh,umn amn Elk River Municpal Utilities
street 13069 Orono Parkway
city Elk River State MN Zip 55330
Industry description (e.g., Manufacture ofmotor truck trailers)
Municipal utility - electric and water
North American Industrial Classification (NAICS),ifknown (e.g., 336212)
221122
Employment information (Ifyou don't have these figures, see the
Worksheet on the nest page to estimate)
Annual average number of employees 47
Total hours worked by all employees lastyear 84,585.68
Sign here
Knowingly falsifying this document may result in a fine.
I certify that I have examined,is document and that to the best of
my k ledge.the e5tries ace' true, accurate, and complete.
Company executive Title
Phone(763) 441-2020 Date 0 1 /27/2023
Reset
M]