4.2a ERMUSR 02-13-2024OSHA's Form 300A (Rev. 0412004) Note: You can type Input Into this form and save it. Year ZO
Because the forms in this recordkeeping package are "fillablelwritable° 23
PDF documents, you can type Into the Input form fields and U.S. De artment of Labor
Summary of Work -Related Injuries and Illnesses then save your inputs using the free Adobe PDF Reader, p
U.S.
S. D and tin Admirr/Labor
,•,.J. �. - - Font approved OMBno. 12180176
All establishments covered by Part 1904 must complete this Summary page, even if no work -related Injuries orillnesses 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 mcordkesping 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 transferor other recordable
away from work restriction cases
0 1 0 5
(a) (H) (I) (J)
Total number of days
away from work
5
(K)
Total number of...
(M)
(1) Injuries
(2) Skin disorders
(3) Respiratory conditions
Total number of days of
,job transfer or restriction
Aa
0
6 (4). poisonings 0
0 (5) gearing loss 0
0 (6) All other illnesses 0
Post this Summary page from February t to April 30 of the year following the year covered by the form
street 13069 Orono Parkway
oiryElk River Stara MN Zip 55330
Industry description (e.g., Mmn facrum of mafor truck frallers)
Municipal Utility - Electric and Water
North American Industrial Classification (NAICS), ifknown (e.g„ 336212)
1212111112121
Employment information (Ifyou don't It— these figures, seethe
I'lorksheet on the next page to tefieude.)
Annual average number of employees 46
Total hours worked by all employees last year 84,026.00
Sign here
Knowingly falsifying this document may result in a fore.
I certify that I have examined this document and that to the /best of
a my�� kyo},vledge antr~ re�true, accurate, an complete
Company executive
Phnnc763-441-2020 Date February 6, 2024
Reset
Publie repotting buicn 16r11e, collegian ofinrom u'ns unmated to avoruge 58 minutes perresponse, inoludinb nme to review doe insweuo.,—M, and gather Iht dolt needed, and
o,ko,vid-i—theeollectionofinfommtian. Persons are notrequired to respond to the collection orins ... roe unless it disploys o currently valid OMB conhol number. Vyoo hove ony
menie nbool these estimates ar ony o@a ospecta orthis data collection, conlann US Depnronent or Lobar, OSHA Off' —of St.tkticol A-1,6s, Room N-3644, No Cans aoflon Avenuq NW,
�tl hinglon, DC 202111. Do not send the completed forms to this office.
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