4.1b ERMUSR 02-14-2023HAs Form 300A (Rev. 0412004) Note: You can type input into this form and save it. Y@ciC 2O Because the forms in this recordkeeping package are "fi Ila ble/writable" 21
PDF documents, you can type into the input form fields and —
Summary of Work -Related Injuries and Illnesses then save your inputs using the free Adobe PDF Reader. U.S. Department of Labor
Occupational Safety and Hearth Administration
Form enoroved OMR ne 191 R-0176
All establishments covered by Part 1904 must complete this Summary page, 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.
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
0
0
1
1
(G)
(H)
(I)
(d)
NumberofDays
Total number of days
Total number of days of
away from work
job transfer or restriction
0
30
(K)
(L)
Injury and Illness
Total number of...
Types
(M)
(1) Injuries
2
(4) Poisonings
0
(2) Skin disorders
0
(5) Hearing loss
0
(3) Respiratory conditions 0
(6) All other illnesses
0
Post this Summary page 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 review the instructions, search and gather the dataneeded, 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. [f you have any
comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitmion Avenue, Nw,
washington, DC 20210. Do not send the completed forms to this office.
59
Establishment information
Yourestabltahmentname Elk River Municipal Utilities
street 13069 Orono Parkway
City Elk River state MN Zip 55330
Industry description (e.g., Manufacture of motor truck trailers)
Municipal Utility - Electric and Water
North American Industrial Classification (NAICS), if known (e.g., 336212)
2 2 1 1 2 2
Employment information (If you don't have these figures, see the
Worksheet on the next page to estimate.)
Annual average number of employees 45
Total hours worked by all employees last year 84,317.00
Sign here
Knowingly falsifying this document may result in a fine.
I certify that I have examined this document and that to the best of
my knowledge the ntries are true, accurate, and complete.
Comp executive Title
Phone 763-441-2020 Date / 28 2dZZ
Reset
Y"