Semi-Annual Report Form | Greater Cleveland Safety Council

Please complete the form below to submit your information for the last 6 months.

Safety Council Account Number (Risk Number)*
Company Name*
Address*
Street AddressAddress Line 2CityStateZip Code
Business Phone*
Business Fax
Your Name*
FirstLast
Your Email*
Date of Submission*
MM
DD
YYYY
Last Injury or Illness*
MM
DD
YYYY
Date of Most Recent Injury or Illness Resulting in Day(s) Away from Work
Average Number of Employees*
Full-Time & Part-Time
Total Hours Worked*
Total Hours for the Entire Six Month Period for All Employees
Number of Deaths*
You May Use Your OSHA 300 Log
Number of Injuries*
Number of occupational injuries and/or illnesses resulting in days away from work. You may use your OSHA 300 Log.
Days Away From Work*
Number of days away from work as a result of occupational injuries and/or illnesses. You may use your OSHA 300 Log. Please include any days taken during this 6 month period, even if injury or illness occurred before this 6 month period.