Second Half 2019 semi-annual reports are due by January 15, 2020. All companies actively participating in Safety Council are required to submit this report on time.

The form can be printed and completed HERE or completed electronically via the online form below.

Instructions for completing the Semi-annual report are attached in the above link.

If you have further questions, please email safety@medinaohchamber.com or call 330-723-8773.

Medina County Safety Council

Semi-Annual Report * SECOND HALF 2019* JULY 1, 2019 - DECEMBER 31, 2019

DUE by January 15, 2020

Safety Council Account Number (BWC policy number)

Company Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Submitted by:

First Name

Last Name

Email 1

Phone

(###)

###

####

1. DATE OF MOST RECENT INJURY OR ILLNESS RESULTING IN DAY(S) AWAY FROM WORK

If there were none between July 1, 2019 and December 31, 2019 go back to the most recent injury or illness date resulting in days away from work

2. Average Number of Employees

3. Total Hours Worked (entire six month period, all employees)

4. Number of Deaths (column G in OSHA 300 log/PERRP form 300P)

5. Number of Occupationial injuries and/or illnesses resulting in days away from work (column H in the OSHA 300 log/PERRP From 300P)

6. Number of days away from work as a result of occupational injuries and/or illnesses (column K in the OSHA 300 log/PERRP From 300P)

*Report all information for the CURRENT SIX MONTH PERIOD ONLY: JULY 1, 2019 - December 31, 2019

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.