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09/15/2010
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Safety Council & Group Rating

Co-sponsored by BWC's Division of Safety and Hygiene

To submit your Safety Council Reports, fill out the form below and click Submit.
Required fields are described in bold.
Report Period: 1st Report (due by July 15) for period January 1 - June 30
2nd Report (due by January 15) for period July 1 - December 31
SC Account #:
Company Name:
Address:
City/State/Zip:
Phone: include area code
Fax: include area code
Submitted By:
Email:
Date:
Please check here if information provided above has been updated on this report
  1. Date of MOST RECENT injury or illness resulting in day(s) away from work
mm/dd/yyyy

Report All Information Below For CURRENT SIX MONTH PERIOD ONLY (corresponds with period identified above)
  1. Avg. # of Employees
  1. Total Hours Worked (entire six month period, all employees)

Items 4, 5, and 6 are based on the Recordkeeping Requirements under the Occupational Safety & Health Act of 1970 (rev. 1/1/02). The columns listed below correspond to the columns in the OSHA 300 Log.

  1. Number of Deaths (column G in OSHA 300 Log)
  1. Number of occupational injuries and/or illnesses resulting in days away from work (column H in OSHA 300 Log)
  1. Number of days away from work as a result of occupational injuries and/or illness (column K in OSHA 300 Log)

Note: If you report a death, injury, or illness resulting in days away from work in the current six month period (item 4 or 5), the most recent date of death, injury, or illness must correspond with item 1.