4.4a EMRUSR 02-11-2025OSHA -is Form 300A (Rev. 04/2004) Note: You can type input into this form and save it. Year 20
Because the forms in this recordkeeping package are "fillable/writable" 24
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 Health Adminiatratton
F.— approved OMB no. 121 M 176
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 complefrng 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
deaths cases with days
away from work
0 0
(G) (H)
Total number of days
away from work
0
(K)
Total number of cases Total number of
with job transfer or other recordable
restriction cases
0 2
Total number of days of
job transfer or restriction
0
(L)
Total number of...
(M)
(1) Injuries 1 (4) Poisonings 0
(2) Skin disorders 0 (5) Hearing loss 1
(3) Respiratory conditions 0 (6) All other illnesses 0
W)
Post this Summary page from February Ito Apr1130 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 rexim the instructions- search and gather the dam needed, and
complete and redmv the collection of information. Persons arc not required to respond to the collection of information unless it displays a current, valid OMB central number, if you heoe am_ -
comments about these estimates or any other aspects of this data collection_ contact: US Depamneat of Labor. OSHA Office of Statistical Analysis, Room N-3644_ 200 Constitution Avenue. NW.
Washington. DC 20210_ Do not scud the completed forms to this office_
Establishment information
Yourestablishmentname Elk River Municipal Utilities
street 13069 Orono Parkway
Cin,Elk River state MN Zip 55330
Industry description (e.g., Manufacture of motor track trailers)
Municipal Utility - Electric and Water
North American Industrial Classification (NAICS), if known (e.g., 336212)
221122
Employment information (!f you don't have these figures, see the
Worksheei on the next page to estimate)
Annual average number of employees 45
Total hours worked by all employees last year 81,896.59
Sign here
Knowingly falsifying this document may result in a fine.
I ccrtify that I have examined this document and that to the best of
my kno vledge tries az e, accurate, and complete.
17
Company executive �Title
Phone(763) 441-2020 Date January 31, 2025
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