4.2b ERMUSR 02-13-2024OSHA's Form 300A (Rev. 04/2004) Note: You can type input into this form and save it
Because the forms in this recordkeeping package are'fillableNvntable"
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.
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.
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
0 0 0 1
(G) (H) (1) (J)
Number of Days
'total number of days Total number of days of
awav from workjob transfer or restriction
n n
(K) (L)
Total number of...
(M)
(1) Injuries 1
(2) Skin disorders 0
(3) Respiratory conditions 0
(4) Poisonings 0
(5) hearing loss 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
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Year 20 99
U.S. Department of Labor
Form approved OMB ao. 121-1l6
Estabfishment information
Elk River Municpal Utilities
Street 13069 Orono Parkway
cm Elk River state MN Zip 55330
Industry description (e.g- Man f crurc of motor tuck waiters)
Municipal utility - electric and water
North American Industrial Classification (NAICS), ifknown (e.g., 336212)
221122
Employment information pfyou don't hose these figurer, see Inc
Workslaeet on the ,test page to estfmate.J
Annual average number ofemployees 47
Total hours worked by all employees last Year 84,585.68
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Knowingly falsifying this document may result in a fine.
I cenifv that I have examined is document and that to the best of
my k led,P\fire ertm.es aCetrue, accurate, and compl:etef.J
Company executive Title
Phone(763) 441-2020 Dats01/27/2023
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