GSA3624

Log of Federal Occupational Injuries and Illnesses

Agency
GSA
Revision
Rev. 4/1991
Fillable fields
404
Pages
3
Official source
GSA form page
Checked
October 20, 2026
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Page 1 of form GSA3624

GSA Form 3624: Log of Federal Occupational Injuries and Illnesses

GSA Form 3624, Log of Federal Occupational Injuries and Illnesses, is a General Services Administration form. The footer reads GENERAL SERVICES ADMINISTRATION and GSA FORM 3624 (4-91), and GSA hosts it in its forms library, where the page lists the authority or regulation PBS P 5900.2C and a current revision date of 04/1991.

The instructions say Title 29, Code of Federal Regulations, Part 1960.67(a) requires a record or log of occupational injuries and illnesses to be maintained at the establishment, and that each GSA facility or activity defined as an establishment maintains this log on a fiscal year basis. Each row records one case: a file number, the date, the employee, occupation, department, a description, and injury or illness columns.

The PDF has Copy 1 for posting, Copy 2 for the file and a page of instructions. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of GSA Form 3624: Log of Federal Occupational Injuries and Illnesses, as printed by GSA

What's on GSA Form 3624

Items 1 to 3: page and establishment

Page number of the total pages, the name of the GSA establishment and its address.

Columns 4 to 6: case and employee

The file number, the date of injury or onset of illness, and the name of the employee.

Columns 7 to 9: work and injury

The employee's occupation, such as Carpenter or Clerk Typist, the office, shop or department, and a description of the injury or illness and body part affected.

Column 10: injuries

Three columns: (A) fatal cases, (B) lost time cases and (C) no lost time cases.

Column 11: illnesses and diseases

The same three columns, (A) fatal, (B) lost time and (C) no lost time, for illnesses.

Totals and copies

A totals row at the bottom, Copy 1 marked POSTING, Copy 2, and a page of instructions.

How to complete GSA Form 3624

  1. 1

    Number each case

    Column 4 is a five digit number: the last two digits of the fiscal year, a dash and a sequence starting at 001. The form's example, 92-010, is the tenth injury or illness reported in fiscal year 1992.

  2. 2

    Enter the case details

    Fill in the date, employee name, occupation, department and a description of the injury or illness and body part affected.

  3. 3

    Mark the injury columns

    Place an X in 10(A) for a fatal injury. Enter lost workdays in 10(B), not counting the day of injury or the day of return. Place an X in 10(C) for medical treatment without being placed off duty.

  4. 4

    Update lost workday estimates

    If the actual days are not known, the form says to estimate, then line out the estimate and enter the actual days when the employee returns. Workdays exclude days not scheduled, such as Saturdays, Sundays and holidays.

  5. 5

    Total the year

    Apply the same rules to column 11 for illnesses. At the end of the fiscal year, but no later than November 1, enter the totals at the bottom of the form.

  6. 6

    Separate, post and file

    Copy 1 is separated between columns 6 and 7. The columns 4 to 6 portion is destroyed, the columns 7 to 11 portion is posted for a minimum of 30 calendar days, and Copy 2 is filed.

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Keeping, posting and what the form says

Rule cited on the form

The instructions cite Title 29, Code of Federal Regulations, Part 1960.67(a) for the log and Part 1960.2(h) for the meaning of establishment.

Year end date

Totals are entered at the end of the fiscal year, but no later than November 1. Copy 1 also prints: separate and destroy this portion at the end of the fiscal year or not later than November 1.

Posting period

The posted portion stays up for a minimum of 30 calendar days in a location where employee notices are routinely posted. After that, the form says it may be destroyed.

Retention

The log is maintained on a fiscal year basis, and the form says logs (Copy 2) are retained for a 5-year period.

Authority and edition

GSA's page lists the authority or regulation as PBS P 5900.2C. The footer reads GSA FORM 3624 (4-91). The form prints no OMB number or privacy statement.

Related forms

Who keeps GSA Form 3624?

  • Each GSA establishment

    The instructions say each GSA facility or activity defined as an establishment maintains the log. Items 2 and 3 name the establishment and its address.

  • What counts as an establishment

    A single physical location where business is conducted or services or operations are performed, such as a field office, regional office, distribution center or fleet management office. Distinctly separate activities at one location are each a separate establishment.

  • Employees whose cases are logged

    Each row is one employee's injury or illness. Columns 10 and 11 cover fatal cases, lost time cases and cases with medical treatment but no time off. The form says first aid cases are not listed on the log.

  • Employees who see the posting

    After year end, the part of Copy 1 holding columns 7 to 11 is posted where employee notices are routinely posted. Employee names and file numbers are on the part that is destroyed.

The instructions page describes who maintains the log and whose cases go on it.

Official sources and the blank

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Questions about Form GSA3624

Who issues GSA Form 3624?

The footer reads GENERAL SERVICES ADMINISTRATION and GSA FORM 3624 (4-91). GSA hosts it in its forms library and its page lists the authority or regulation PBS P 5900.2C.

Who keeps the log?

The instructions say each GSA facility or activity defined as an establishment maintains it, such as a field office, regional office, distribution center or fleet management office.

How is the file number written?

The last two digits of the current fiscal year, a dash and a three digit sequence starting at 001. The form's example, 92-010, is the tenth injury or illness reported during fiscal year 1992.

Are first aid cases entered?

No. The instructions say first aid cases are not listed on the log.

How are lost workdays counted?

The form says not to count the day of injury or the day of return, and that workdays do not include days the employee is not scheduled to work, such as Saturdays, Sundays and holidays.

What happens at the end of the fiscal year?

No later than November 1, the totals are entered. Copy 1 is separated between columns 6 and 7, the part with columns 4 to 6 is destroyed, and the part with columns 7 to 11 is posted for a minimum of 30 calendar days.

How long is the log kept?

The instructions say logs (Copy 2 of the form) are retained for a 5-year period.