OSHA's Form 300A «rev. 01/2004)
Summary of Work-Related Injuries and Illnesses
All establishments covered by Part 1904 must complete this Summary page, even if no injuries or
illnesses occurred during the year. Remember to review the Log to verify that the entries are complete
Using the Log, count the individual entries you made for each category. Then write the totals below,
making sure you've added the entries from every page of the fog. if you had no cases write "0."
Employees former employees, and their representatives have the right to review the OSHA Form 300 in
its entirety. They also have limited access to the OSHA Form 301 or its equivalent. See 29 CFR
1904.35, in OSHA's Recordkeeping rule, for further details on the access provisions for these forms.
Number of Cases
Total number of
deaths
Total number of
cases with days
Total number of
other recordable
Total number of cases
with job transfer or
away from work __ restriction cases
0 0 0
G) (H) a) W)
Number of Days
Total number of Total number of days of
days away from job transfer or restriction
wiark
0 0
(K) (D
Injury and Illness Types
Total number of...
(™)
(1) Injury 0 (4) Poisoning 0
(2) Skin Disorder 0 (5) Hearing Loss 0
(3) Respiratory
Condition 0 (6) All Other Illnesses 8]
Post this Summary page from February 1 to April 30 of the year following the year covered by the form
Public reporting burden for this collection of information is estimated to average 58 minutes per response, including time to review the instruction, search and
gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it
displays a currently valid OMB control number. If you have any comments about these estimates or any aspects of this data collection, contact: US Department
of | ahor OSHA Office of Statistics Room N-3844 900 Constitution Ava NW Washinaton NC 20210 No not sand the enmoleted forms to this office
U.S. Department of Labor
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
Establishment information
Your establishment name Schroeder Construction Management, Inc.
Street 2 Townsend West #3
City Nashua State New Hampshire
Zip 03063
Industry description (e.g., Manufacture of motor truck trailers)
Construction management
Standard Industrial Classification (SIC), if known (e.g., SIC 3715)
1 7 5 1
OR North American Industrial Classification (NAICS), if known (e.g., 336212)
2 3 6 2 2 ie]
Employment information
Annual average number of employees 10
Total hours worked by all employees last
year 22,098
Sign here
Knowingly falsifying this document may result in a fine.
| certify that | have examined this document and that to the best of my knowledge the entries are true, accurate, and
camplete.
John E. Schroeder
Company executive
603-882-1822
Phone
President
Title
1168/2021
Date
