Agency Schedule Detail

Authorization Number : 580-0249

Agency Series No. : SAF-01

Status : Active

Agency Web Link :

Agency : DMH

Confidential Description :

Division :

Vital Description :

Section :

Record Title : Accident or Illness Report (ADM-4303) (OSHA-101)

Revision : 0

Record Description : Used to report an occupational injury or illness occurring to an employee and provide Workmen's Compensation certification information to the Department of Administrative Services. Also used as OSHA-101 for the Public Employee's Safety and Health Program in order to report and document "OSHA" recordable injuries and illnesses.

Retention Period	Retention Justification	Media Code	Method of Disposal
Original report to be sent to Personnel Office for placement in personnel file. If part of Workmen's Comensation claim file separate from Personnel, retain copy in Safety Unit until claim inactive or when employee ceases employment then send to Personnel Office for placement in personnel file. Retain copies of the report as part of an annual cumulative recordable accident file current year and 5 years past, then destroy.Retain copies of report as part of a continuous chronological file of all accidents reported current year and 5 years past, then destroy	No value at Conversion	Paper	Wastepaper

Approvals

Status	Name	Title	Date
Approved	Transfer User	Records Viewer	6/12/1985 12:00:00 AM

Notes

Date	Reason	User