Form 300A (Rev 0112004) Summary of Work-Related Injuries and Illnesses 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 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 on'ts equivalent. See 29 CFR Part 1904.35. in OSHA's recordkeeping rule. for further details on the access provisions for these forms Number of Cases Total number Total number of cases with days Total number of cases with job Total number of other of deaths away from work transfer or restriction recordable cases 0 217 383 122 (G) (H) (I) (J) Number of Days Total number of days away from work Total number of days of job transfer or restriction 7619 28514 (K) (L) Injury and Illness Types Total number (M) (1). Injuries - 715 (4). Poisonings - 0 (2). Skin Disorders - 6 (5) Hearing Loss - 0 (3). Respiratory conditions - 1 (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 data needed. 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 If you have any comments about these estimates or any other aspects of this data collection. contact: US Department of Labor. OSHA Of?ce of Statistical Analysis. Room 200 Constitution Avenue. NW. Washington. DC 20210 Do not send the completed forms to this of?ce U.S. Department of Labor Occupational Safety and Health Administration Form approved OMB no 1218-0176 Establishment information Your Establishment Name Street 45500 Fremont City Fremont State California ZIP Industry description (e 9 Manufacture of motor truck trailer) 0 le 1' ri Standard Industrial Classification (SIC). if known (eg. 3715) 371 1 OR North American Industrial Classification (NAICS). if known (9.9., 336212) 336111 Employment informationmyou dont have these ?gures. see the worksheet on the back of this page forestimate) Annual average number of employees 10878 Total hours worked by aliemployEEs Ia year 2319495015 Sign here am (my? i443! Knowingly falsifyi 9 this docu at may result in a ?ne. I certify that I have examined this document and that to the best of my knowledge the entries are true. accurate. and complete. Pelertl?hnoldinger Vice Pre to F'r I Company Executive Title (650) 681-5000 Phone Data-