Work injury report form for drivers and office staff: what to record and the deadlines that start that day
Overview
An employee injury report records who was hurt, when and where, what the person was doing, what happened, and the treatment, on the day it happens. With OSHA's Form 301 items it can double as your OSHA record. A death must reach OSHA within 8 hours, a hospital stay within 24, and insurer first reports run on short state clocks, such as 7 days in Florida and 8 in Texas.
On this page
This is the report for a driver, attendant, dispatcher, or mechanic who gets hurt at work: a strained back from a transfer, a crash, a fall on an icy curb. A hurt rider goes on the incident report instead. The coverage rules, costs, and claim basics are in the workers’ compensation guide, and which injuries OSHA wants logged is in the OSHA guide for NEMT companies. This page is the form itself and the clocks that start when it is filled in.
How to fill it in
Fill it in the day it happens: the employee describes the event in their own words, and a supervisor completes everything else from records, not from memory.
- Hand it over before the shift ends. If the employee cannot write, a supervisor writes Part C as the employee says it, reads it back, and records the time.
- Pull the times from the trip record. The shift start, the time of the event, and the trip number are facts on file, so copy them in.
- Keep names out of Part C. OSHA’s Form 301 tells the filer not to put names, phone numbers, or Social Security numbers into the four narrative questions. For example, write “the rider on trip 1482” and “a dispatcher,” not names.
- Leave fault out. “Slipped on ice at the curb at 7:40” belongs on the form. “Careless” does not.
- Give the employee a copy and tell them they may report an injury without penalty (the statement is printed above the signature line).
The form
Parts A to F ask for everything on OSHA’s Form 301, which has 18 items, and for what the insurer’s first report needs. A substitute counts as an equivalent only if it holds all of the Form 301 information, so do not drop a line when you adapt this form.
Part A: The employee
| Field | Entry |
|---|---|
| Full name | |
| Job title and date hired | |
| Date of birth and sex | |
| Home address and phone | |
| Language the employee prefers | |
| Pay rate and usual hours per week | |
| Paid for the day of the injury | [ ] Yes [ ] No |
Part B: When and where
| Field | Entry |
|---|---|
| Date of the injury | |
| Time the shift began (from the time record) | |
| Time of the event | |
| Where it happened (address or road) and vehicle number | |
| Trip number, if on a trip (no rider name) | |
| When and to whom the employee reported it | |
| Date and time the company first knew | |
| Witnesses (names and phone numbers) |
Part C: What happened, in the employee’s words
| Field | Entry |
|---|---|
| What was the employee doing just before it happened? Name the task and any equipment. | |
| What happened? Tell how it started and how the injury occurred. | |
| What was the injury, and which part of the body? | |
| What object or substance directly harmed the employee (for example a ramp edge, a wheelchair, ice, a seat belt buckle)? |
Part D: Task and conditions
| Field | Entry |
|---|---|
| Task | [ ] Helping a rider transfer [ ] Pushing a wheelchair [ ] Lift, ramp, or tiedown [ ] Stair chair or stretcher [ ] Crash [ ] Slip, trip, or fall [ ] Aggression by a rider or visitor [ ] Animal bite [ ] Blood or a needle (also complete the exposure incident report) [ ] Other |
| Was a second person helping? | [ ] Yes [ ] No |
| Equipment in use (gait belt, slide board, lift, stair chair) | |
| How much of the rider’s weight was the employee holding, and could the rider help? | |
| Weather, surface, and light |
Part E: Treatment
| Field | Entry |
|---|---|
| First aid at the scene, and by whom | |
| Doctor, clinic, or hospital (name and address) | |
| Treated in an emergency room | [ ] Yes [ ] No |
| Admitted overnight as an in-patient | [ ] Yes [ ] No |
| First day missed, and date returned | |
| Work restrictions from the doctor (attach the note) | |
| Date of death, if the employee died |
Part F: The company’s clocks
| Clock | Applies when | Done (date, time, by whom) |
|---|---|---|
| OSHA call within 8 hours | Death | |
| OSHA call within 24 hours | Hospital admission for care, amputation, or loss of an eye | |
| OSHA 300 log and 301 within 7 calendar days | Recordable case, and you keep OSHA logs | |
| First report to the insurer | See the state table below | |
| Case number from the OSHA 300 log | You keep OSHA logs | |
| Claim form or copy given to the employee | Where your state requires it |
Part G: Signatures
The employee’s statement: “This report matches what I told [supervisor’s name]. I was told I have the right to report a work injury or illness, and that [Company name] does not discharge or penalize anyone for reporting one.”
Employee signature: __________ Date: __________
Completed by: __________ Title: __________ Phone: __________ Date: __________
Which deadlines start the day someone is hurt?
Up to five clocks can start the same day, and which ones apply depends on how serious the injury is, how many people you employ, and your state.
- 8 hours, a death. Report a work-related death to OSHA within 8 hours of learning of it, if it happens within 30 days of the incident.
- 24 hours, a serious injury. Report an in-patient hospital admission for care or treatment, an amputation, or the loss of an eye within 24 hours of learning of it, if it happened within 24 hours of the incident. Observation or diagnostic testing alone does not count. Call 1-800-321-6742 or report online at osha.gov. Both reports apply to every employer, however small, and the OSHA guide has the rest of the reporting rules.
- 7 calendar days, the OSHA record. Where you keep OSHA logs, the 300 log line and the 301 are due within 7 days of learning that a recordable injury happened.
- A state clock, the insurer. The table below gives three examples.
- Next business day, the employee’s copy. An employee who asks for their 301 gets it by the end of the next business day.
A crash on an ordinary public road is not called in to OSHA unless it happened in a construction work zone, but it is still recorded when you keep logs. The van accident guide covers the police, broker, and insurance reports for the vehicle side.
The insurer’s first report runs on the state’s clock, which starts at different moments.
| State | The clock starts when | What you send, and by when |
|---|---|---|
| Florida | The company, or its agent, has actual knowledge of the injury or death | A report to your insurer within 7 days, with a copy to the employee |
| Texas | The employee’s first day absent from work because of the injury, notice of an occupational disease, or a death | If you carry workers’ comp, DWC Form-001 to your insurer and the employee within 8 days |
| California | The employee files the DWC 1 claim form | The employer section completed, dated, and copied to the claims administrator and employee within 1 working day |
In Florida, a late employer report can draw a fine of up to $500 each time, and the employer pays it, not the insurer. A Texas employer without workers’ comp coverage reports to the state’s workers’ compensation division instead, for any injury with more than one day of lost time, any work-related illness, and any death. California adds two more clocks. Form 5020, the employer’s report, is due within 5 days of knowing about an injury that costs lost time beyond the day of the incident or needs treatment beyond first aid. A serious injury must also reach Cal/OSHA immediately, and no later than 8 hours after you know. For any other state, ask your insurer for its form and deadline, and send the same facts.
Does your company have to keep OSHA’s Form 301?
Only if your company had more than 10 employees at any time last calendar year, counted across the whole company at its peak. Nonemergency medical transportation is classified under NAICS 485991, which is not on OSHA’s list of partially exempt industries, so headcount is the only test. The OSHA guide covers which cases are recordable and how to post the yearly summary.
When the rule applies, this form is your 301 as long as it holds the same information, is as readable, and is completed the same way. Keep it five years after the end of the calendar year it covers, and give the injured employee a copy by the end of the next business day when they ask.
What the lifting questions in Part D are for
Part D asks how much of the rider’s weight the employee was holding because NIOSH treats that number as a threshold. Its patient handling curriculum says that if any caregiver must lift more than 35 pounds of a patient’s weight during a transfer, the patient should be treated as fully dependent and assistive devices used. A driver who strained a shoulder holding up a rider who could not bear weight is a different case from one who slipped getting out of the van. The answer tells you whether to change the equipment, the crew, or the trip’s service level. The steps for that review are in the incident investigation guide, and the transfer methods themselves are in safe rider transfers.
Why nobody is disciplined for filing it
The rule is plain: you must have a reasonable way for employees to report a work injury promptly and accurately, and a procedure is not reasonable if it would deter or discourage a reasonable employee from reporting accurately. You must tell each employee how to report, that they have the right to, and that retaliation is prohibited. You may not discharge or discriminate against anyone for reporting.
Section 11(c) of the OSH Act adds a second layer. An employee who thinks they were punished for reporting has 30 days after the violation to file a complaint with the Secretary of Labor, and later complaints are ordinarily presumed stale. Safety bonuses that vanish when someone reports an injury raise the same question, which the driver bonus guide walks through.
Pulling the times from the record in HealthRide
Parts B and E ask for times the company already has. In HealthRide, each trip saves its timestamps and GPS-recorded miles, so the trip number on the form leads to the vehicle, the driver, and the pickup and drop-off times. Drivers clock in and out in the driver app, and the reports page lists driver hours from those clock-ins, so the shift start that Part B asks for is already on record. Dispatch can reassign the rest of the day’s trips on the board while the supervisor completes the report.
Frequently asked questions
- Who fills in the form when the employee is too hurt to write?
- A supervisor writes Part C from what the employee says, reads it back, and notes the date and time. The employee signs later if able. Do not guess at details. If the person cannot speak yet, record only what a witness saw and the trip record shows, and mark the employee's account as pending.
- Does this form replace the workers' comp claim form?
- No. The injured employee's claim and your first report to the insurer are separate state forms. California uses the employee's claim form, the DWC 1. Florida (DWC-1) and Texas (DWC Form-001) use the employer's first report. This form collects the facts once so you can copy them across, and it can serve as the OSHA 301 where you keep OSHA logs.
- What if the employee reports the injury days or weeks later?
- Take the report and start your clocks from the day the company learned of it. Florida gives an employee 30 days to report an injury, and Texas gives 30 days if the employer carries coverage. OSHA also says a reporting procedure is not reasonable if it would deter a reasonable employee from reporting accurately, so a rule that penalizes a late report invites that question.
- Do I have to call OSHA about a driver hurt in a crash on a public road?
- Generally no. OSHA drops the 8-hour and 24-hour calls for a crash on an ordinary public road, with one exception: a crash inside a construction work zone must still be called in. The injury still goes in your OSHA records if you keep them. California's serious injury rule has the same public road exclusion. Report to your insurer and your state workers' comp agency as usual.
- Does the employee get a copy of the report?
- Yes, if the case is on your OSHA records. An employee, former employee, or personal representative who asks for the OSHA 301 or an equivalent must get a copy by the end of the next business day, and the first copy is free. Even where you keep no OSHA logs, give the employee a copy of what you send the insurer, since California, Florida, and Texas each have the employee receive one.
- Where do I file the completed form?
- In a locked injury or medical file, not the general personnel file. OSHA's own Form 301 carries a notice that it holds employee health information and must be used so as to protect confidentiality. If you keep OSHA logs, hold the 301 or its equivalent for five years after the end of the calendar year it covers.
