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North Carolina Department of Environment Quality

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Human Resources - Recordkeeping Basics

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Recordkeeping basics

The following information should help as you maintain your Log through-out the calendar year.

What you need to do

  1. Within 7 calendar days after you receive information about a case, decide if the case is recordable under the OSHA recordkeeping requirements.
  2. Determine whether the incident is a new case or a recurrence of an existing
  3. Establish whether the case was work-related If the case is recordable, you will need to fill out the standard NCIC Form 19.

When is an injury or illness considered work-related?

An injury or illness is considered work-related if an event or exposure in the work environment caused or contributed to the condition or significantly aggravated a preexisting condition. Work-relatedness is presumed for injuries and illnesses resulting
from events or exposures occurring in the workplace, unless an exception specifically
applies. See 29 CFR Part 1904.5(b)(2) for the exceptions. The work environment includes the establishment and other locations where one or more employees are working or are present as a condition of their employment. See 29 CFR Part 1904.5(b)(1).

Which work-related injuries & illnesses should you record?

Record those work-related injuries and illnesses that result in:

  • death,
  • loss of consciousness,
  • days away from work,
  • restricted work activity or job transfer, or
  • medical treatment beyond first aid.

You must also record work-related injuries and illnesses that are significant (as defined
below) or meet any of the additional criteria listed below.

You must record any significant work-related injury or illness that is diagnosed by a
physician or other licensed health care professional. You must record any work-related
case involving cancer, chronic irreversible disease, a fractured or cracked bone, or a
punctured eardrum. See 29 CFR 1904.7.

Are there additional criteria to consider?

You must record the following conditions when they are work-related:

  • any needlestick injury or cut from a sharp object that is contaminated with another person’s blood or other potentially infectious material;
  • any case requiring an employee to be medically removed under the requirements
    of an OSHA health standard;
  • tuberculosis infection as evidenced by a positive skin test or diagnosis by a physician or other licensed health care professional after exposure to a known case of active tuberculosis.
  • an employee's hearing test (audiogram) reveals 1) that the employee has
    experienced a Standard Threshold Shift (STS) in hearing in one or both ears
    (averaged at 2000, 3000, and 4000 Hz) and 2) the employee's total hearing level is 25 decibels (dB) or more above audiometric zero ( also averaged at 2000, 3000, and 4000 Hz) in the same ear(s) as the STS.

What is medical treatment?

Medical treatment includes managing and caring for a patient for the purpose of
combating disease or disorder. The following are not considered medical treatments and are NOT recordable:

  • visits to a doctor or health care professional solely for observation or counseling;
  • diagnostic procedures, including administering prescription medications that
    are used solely for diagnostic purposes; and any procedure that can be labeled first aid. (See below for more information about first aid)

What is first aid?

If the incident required only the following types of treatment, consider it first aid. Do NOT record the case if it involves only:

  • using non-prescription medications at nonprescription strength;
  • administering tetanus immunizations;
  • cleaning, flushing, or soaking wounds on the skin surface;
  • using wound coverings, such as bandages, BandAids™, gauze pads, etc., or using
    SteriStrips™ or butterfly bandages.
  • using hot or cold therapy;
  • using any totally non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc.;
  • using temporary immobilization devices while transporting an accident victim
    (splints, slings, neck collars, or back boards).
  • drilling a fingernail or toenail to relieve pressure, or draining fluids from blisters;
    using eye patches;
  • using simple irrigation or a cotton swab to remove foreign bodies not embedded in or adhered to the eye;
  • using irrigation, tweezers, cotton swab or other simple means to remove splinters or foreign material from areas other than the eye;
  • using finger guards;
  • using massages;
  • drinking fluids to relieve heat stress.

What is considered 'restricted work'?

Restricted work activity occurs when, as the result of a work-related injury or illness, an
employer or health care professional keeps, or recommends keeping, an employee from doing the routine functions of his or her job or from working the full workday that the employee would have been scheduled to work before the injury or illness occurred.

How do you count the days of restricted work or days away from work?

Count the number of calendar days the employee was on restricted work activity or was
away from work as a result of the recordable injury or illness. Do not count the day on which the injury or illness occurred in this number. Begin counting days from the day after the incident occurs. If a single injury or illness involved both days away from work and days of restricted work activity, enter the total number of days for each. You may stop counting days of restricted work activity or days away from work once the total of either or the combination of both reaches 180 days.

What is considered a 'privacy case'?

You must consider the following types of injuries or illnesses to be privacy concern cases:

  • an injury or illness to an intimate body part or to the reproductive system,
  • an injury or illness resulting from a sexual assault,
  • a mental illness,
  • a case of HIV infection, hepatitis, or tuberculosis,
  • a needlestick injury or cut from a sharp object that is contaminated with blood or
    other potentially infectious material (see 29 CFR Part 1904.8 for definition), and
  • other illnesses, if the employee independently and voluntarily requests that his or her name not be entered on the log.

You must not enter the employee’s name on the OSHA 300 Log for these cases. Instead, enter “privacy case” in the space normally used for the employee’s name. You must keep a separate, confidential list of the case numbers and employee names for the establishment’s privacy concern cases so that you can update the cases and provide information to the government if asked to do so. If you have a reasonable basis to believe that information describing the privacy concern case may be personally identifiable even though the employee’s name has been omitted, you may use discretion in describing the injury or illness on both the OSHA 300 and 301 forms. You
must enter enough information to identify the cause of the incident and the general severity of the injury or illness, but you do not need to include details of an intimate or private nature.

What if the outcome changes after you record the case?

If the outcome or extent of an injury or illness changes after you have recorded the case, simply draw a line through the original entry or, if you wish, delete or white-out the original entry. Then write the new entry where it belongs. Remember, you need to record the most serious outcome for each case.

Classifying injuries

An injury is any wound or damage to the body resulting from an event in the work environment.


Cut, puncture, laceration, abrasion, fracture, bruise, amputation, insect bite, electrocution, or a thermal, chemical, electrical, or radiation burn. Sprain and strain injuries to muscles, joints, and connective tissues are classified as injuries when they result from a slip, trip, fall or other similar accidents.

Classifying illnesses

Skin diseases or disorders

Skin diseases or disorders are illnesses involving the worker’s skin that are caused by work exposure to chemicals, plants, or other substances.
Contact dermatitis, eczema, or rash caused by primary irritants and sensitizers or poisonous plants; oil acne; friction blisters, chrome ulcers; inflammation of the skin.

Repiratory conditions

Respiratory conditions are illnesses associated with breathing hazardous biological agents, chemicals, dust, gases, vapors, or fumes at work.

Silicosis, asbestosis, pneumonitis, pharyngitis, rhinitis or acute congestion; farmer’s lung, beryllium disease, tuberculosis, occupational asthma, reactive airways dysfunction syndrome (RADS), chronic obstructive pulmonary disease (COPD), hypersensitivity pneumonitis, toxic inhalation injury, such as metal fume fever, chronic obstructive bronchitis, and other pneumoconioses.


Poisoning includes disorders evidenced by abnormal concentrations of toxic substances in blood, other tissues, other bodily fluids, or the breath that are caused by the ingestion or absorption of toxic substances into the body.

Poisoning by lead, mercury, cadmium, arsenic, or other metals; poisoning by carbon monoxide, hydrogen sulfide, or other gases; poisoning by benzene, benzol, carbon tetrachloride, or other organic solvents; poisoning by insecticide sprays, such as parathion or lead arsenate; poisoning by other chemicals, such as formaldehyde.

Hearing Loss

Noise-induced hearing loss is defined for recordkeeping purposes as a change in hearing
threshold relative to the baseline audiogram of an average of 10 dB or more in either ear at 2000, 3000 and 4000 hertz.

All other illness

All other occupational illnesses.

Heatstroke, sunstroke, heat exhaustion, heat stress and other effects of environmental heat; freezing, frostbite, and other effects of exposure to low temperatures; decompression sickness; effects of ionizing radiation (isotopes, x-rays, radium); effects of nonionizing radiation (welding flash, ultra-violet rays, lasers); anthrax; bloodborne pathogenic diseases, such as AIDS, HIV, hepatitis B or hepatitis C; brucellosis; malignant or benign tumors; histoplasmosis; coccidioidomycosis.


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