Semi-Annual Report
2016 Second-Half
 Due by January 31, 2017 (for the period July 1 – Dec. 31, 2016)
OH BWC Policy Number: _______________
Avg # Employees (fill-in): _________
Company Name:
______________________________________________________________________
Address:
______________________________________________________________________
City / State / Zip:
______________________________________________________________________
Phone:
_______________________________________
Fax:
_________________________________
Contact Name:
_______________________________________________________________
Contact Title:
_______________________________________________________________
E-Mail Address:
___________________________________
___________________________________________________________________________________________
(1) DATE OF THE LAST (MOST RECENT) INJURY OR ILLNESS RESULTING IN DAY(S) AWAY FROM WORK
CAN BE EITHER BEFORE OR AFTER JULY 1, 2016 BUT NO LATER THAN DEC. 31, 2016.
Do Not Use the word "None."
Date (1)________ / _______ / ________
Month
Day
Year
*****************************************************************************************************
REPORT ALL INFORMATION BELOW FOR THE PERIOD OF JULY 1, 2016 TO DEC. 31, 2016.
(2) Average Number of Employees including Full Time, Part Time & Seasonal ...................................... (2)__________
(3) Total Hours Worked for the entire six month period, all employees: Full Time, Part Time & Seasonal (3) _________
*****************************************************************************************************
Lines 4, 5 and 6 are based on the OSHA Recordkeeping Requirements under the Occupational Safety & Health Act of
1970 (rev. 1/1/02). The columns listed below correspond to the columns in the OSHA 300 Log (Rev. 1/2004).
(4) Number of Deaths If available, see Column G in OSHA 300 Log ................................................................. (4) __________
(5) Total Number of all occupational injuries and/or illnesses during this period resulting in full days away from work
Column H in the OSHA 300 Log ....................................................................................................(5) ___________
(6) Total Number of full days away from work during this period as a result of occupational injuries and/or illnesses
Column K in the new OSHA 300 Log .............................................................................................(6)
Note: If you report a death, injury or illness on Line 4 or 5, then Line 1, must have
been between July 1 and Dec. 31, 2016.
For Internal Use Only:
_____ Excel Roster Column
_____ Enter into BWC Website
_____ SBA Update if nec.
_____ SBA Committee if nec.
MAHONING VALLEY SAFETY COUNCIL MEMBERS
Semi-Annual Reporting Instructions
On the reverse side of this sheet is your Semi-Annual Report Form. These instructions guide
you through completing the form.
IMPORTANT: Write-in any necessary corrections to your company’s contact information. Our
ability to send you timely Safety Council updates depends on your providing us with an accurate
FAX number & E-MAIL address.
To “opt out” from receiving our fax or e-mails notices, write “opt out” where the fax number or
e-mail address would be. FAX the completed form to Fax Number 330-746-0330.
Items 1-6
(1) Date of the Last (or Most Recent) Lost-Time Injury or Illness
This is the date of the most recent injury that resulted in an employee missing at least one full day of work. Do not count ½ days. It
does not have to be during 2014. If there were no injuries during this time, then this date will be before July 1, 2016.
Do Not Use the word "None." There must be a date identified. If no injuries have ever occurred at your company, please insert
the “DEFAULT” date of December 31, XXXX where XXXX is the year before the date the business opened. Example: If a business
opened 6/1/09, and there has never been a time-lost injury, the default date is 12/31/08.
(2) and (3) Average Number of Employees / Total Hours Worked
Multiply the average number of employees x the average number of hours worked per week x 26 weeks (1/2 the year).
Add to that amount, part time & seasonal employees. Numbers need not be exact.
Example:
725 FT employees x 40 hrs./week x 26 wks. = 754,000 hours plus
5 PT employees x 20 hrs./week x 26 wks. = 2,600.
Average # of Employees = 730 (725+5)
Total hours worked = 756,600 (754,000+2,600)
(4) Deaths
Taken from OSHA 300 Log (Rev. 01/2004) - Column G, the number of deaths resulting from an occupational illness or accident during
this six-month period.
(5) Number of Injuries
Taken from OSHA 300 Log (Rev. 01/2004) - Column H, the number of occupational injuries or illnesses resulting in complete days
away from work. Half days do not count.
(6) Number of Workdays Lost
Taken from OSHA 300 Log (Rev. 01/2004) - Column K, the total number of days away from work as a result of occupational accidents
during the six-month period. Half days do not count.
Notes:

If there are days away from work resulting from an injury during a previous six-month period in 2014, those days go on the
previous semi-annual report. Consequently, two (2) semi-annual reports will have to be submitted:
1) an updated semi-annual form for that previous period, adding on the additional workdays lost, and
2) the current semi-annual form. Do not put the days lost from that previous injury onto the current reporting period.

If Item 1, Date of the Last Injury or Illness, was before July 1, 2016, (5) and (6) should be zero (0).

If Item 1, is after July 1, 2016 and before Dec. 31, 2016, then Items 5 and 6 should be more than zero (0).