OSHA Form 196 A

OSHA WORK-RELATED INJURY AND
ILLNESS DATA COLLECTION FORM, 2005
This is the combined data collection form for establishments identified to be in both the OSHA data
collection and the BLS Annual Survey of Occupational Injuries and Illnesses.

OMB No. 1218-0209
Approval Expires 3/31/2007
OSHA Form 196A
(1/2006)

2 0 0 5

U.S. Department of Labor
Occupational Safety and Health Administration

Public Law 91-596
requires you to
participate in the data
initiative collection.

Place Label Here

OSHA estimates that it
will take you, on average,
10 minutes to complete
the forms in this data
collection, including the
time you’ll spend reviewing
the instructions, searching
and gathering the data
needed, and completing and
reviewing 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
regarding these estimates or
any other aspects of this data
collection, send them to:
U.S. Department of Labor
Occupational Safety and
Health Administration
Directorate of Evaluation
and Analysis
Office of Statistical Analysis
Room N-3644
200 Constitution Ave. N.W.
Washington, D.C. 20210

Please Make Any Necessary Corrections to your Establishment Site Address, SIC, and NAICS.

Did you know you can submit your form
electronically on the web?
Access our electronic survey at
http://www.osha.gov/form196/cy05.htm

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SEND COMPLETED
FORM TO ADDRESS
INDICATED ON
MAILING LABEL.

1/25/2006 4:23:23 PM

Dear Employer:
The U.S. Department of Labor, Occupational Safety and Health Administration (OSHA) is working with State agencies to compile
work-related injury and illness data from employers within specific industry and employment size specifications. The information
will be used to focus OSHA activities (inspections, outreach, consultations, technical assistance, and leveraging programs) and to
measure the performance of the Agency in meeting its goal of reducing workplace injuries and illnesses.
We are asking for the totals from your 2005 Summary of Work-Related Injuries and Illnesses (OSHA No. 300A), as well as information about hours worked and employment at your establishment. The Occupational Safety and Health Act, 29 U.S.C.
§§ 657 & 673, and reporting regulations at 29 C.F.R. Part 1904 authorize OSHA to collect the requested information. Please
note that establishments that fail to submit a completed 2005 survey may be subject to OSHA enforcement actions, including
the issuance of a citation and assessment of penalties.
We recognize that responding to our questions may be time consuming for some employers and have made every effort to reduce
the completion time while still obtaining the necessary information. In this spirit, we now provide two means of submitting your
establishment information: (1) by mail or fax, using this hard-copy form, or (2) via the Internet, using a secure electronic version
of this form available on our Web site. Instructions for use of the electronic form are displayed at the Web site. You can access an
electronic survey form by pointing your browser to http://www.osha.gov/form196/cy05.htm and then, when prompted, inputting
your establishment-specific ID number and password (provided in the label on the cover of this form). If you choose this option,
use your browser’s print function to print a copy of the completed form for submission to BLS (see the enclosed survey booklet for
mailing instructions)—and be sure to sign the completed form. If you need help in completing the enclosed survey form or if you
have questions, please call the phone number printed on the cover.
OSHA has initiated a comprehensive approach to monitoring and improving data quality. As part of this approach, OSHA will
audit the injury and illness records of a randomly chosen sample of establishments included in this data collection. We will continue
to evaluate this initiative and will build on the lessons learned to improve OSHA’s ability to protect the health and safety of
America’s workers sensibly and appropriately. We invite your comments as we proceed with this effort. Thank you for helping us
collect accurate information and for participating in the effort to make America’s workplaces safer and healthier.
Occupational Safety and Health Administration
U.S. Department of Labor

Who must complete this form?
All establishments that receive this form should complete and return it or respond via Internet within 30 days, even if they had no
work-related injuries and illnesses recorded on their 2005 OSHA No. 300.

What else do you need?
䉴

Information from your 2005 Summary of Work-Related Injuries and Illnesses (OSHA No. 300A).

What do you need to do?
䉴

Check the address information printed on the cover. Make any corrections necessary on the hardcopy or Web site.

䉴

Complete this form only for the establishment noted on the cover.

䉴

Complete pages 3 and 4. You can either photocopy your OSHA Form 300A or you can transcribe the entries from your
OSHA Form 300A to this survey form.

䉴

On the last page, fill in the name of the person we should call with questions and sign the form.

䉴

Return this form in the enclosed envelope, fax, or respond via Internet within 30 days of the date your establishment received it.

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Establishment Information
Using your completed Calendar Year 2005 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A), copy the establishment information into the boxes below. If these numbers are not available on your OSHA Form 300A, or if your establishment
does not keep records needed to answer (1) and (2) below, you can estimate using the steps that follow.

1. For the reporting site identified on the cover: Enter
the annual average employment for 2005. (You can
copy this from your OSHA Form 300A.)

Annual average number
of employees for 2005

2. For the reporting site identified on the cover:
Enter the total hours worked for 2005. (You can
copy this from your OSHA Form 300A.)

Total hours worked
by all employees in 2005
Note: Total Hours Worked should exclude vacation, sick leave,
holidays, and other non-work time.

If needed: Steps to estimate employment

If needed: Steps to estimate total hours worked

STEP 1: Add the number of employees your establishment paid in every pay period during 2005. Include all
employees: full-time, part-time, temporary, seasonal,
salaried, and hourly.

STEP 1: Find the number of full-time employees in your
establishment for 2005.

Acme Construction pays its employees 26 times each year.
During 2005,
Acme paid this many
employees
1 ..................................... 10
2 ..................................... 0
3 ..................................... 15

ABC Company had 15 full-time employees during 2005.

STEP 2: Multiply this number by the number of hours
worked for a full-time employee in a year. This is equal
to the number of full-time hours worked:

In this pay period

25 ................................... 15
26 ................................... 10
830 (sum)

STEP 2: Divide the sum by the number of pay periods
your establishment had in 2005. Include any pay periods when you had no employees.
Because Acme has 26 pay periods, it would divide its sum by 26.
830 divided by 26 = 31.92

STEP 3: Round the answer to the next highest whole
number. Write the rounded number in the box marked
Annual average number of employees.

ABC Company’s 15 full-time employees worked an average of about
1,760 hours each per year after excluding vacation, sick leave, holidays, and other non-work time. (The hours worked for a full-time
employee in a year may be different at your reporting site)
15 (full-time employees) times 1,760 (hours worked by a full-time
employee in a year) equals 26,400 full-time hours.

STEP 3: Add the number of any overtime hours and the
number of hours worked by other employees (part-time,
temporary, seasonal) to the amount in Step 2:
ABC Company’s full time employees worked a total of 1,500 hours
of overtime. In addition, 3 part time employees worked a total of
2,715 hours during 2005. Adding these hours to those from Step 2:
Full-time hours from Step 2
Overtime hours
Part-time hours

+
+

26,400
1,500
2,715

Total hours worked by all employees in 2005 =

30,615

Acme would round 31.92 to 32 and write that number in
the box marked Annual average number of employees.

3. Check any conditions that might have affected your annual average number of employees or total hours
worked during 2005:
Strike or lockout
Shorter work schedules or fewer pay periods than usual
Shutdown or layoff
Longer work schedules or more pay periods than usual
Seasonal work
Other reason: _____________________________________
Natural disaster or adverse weather conditions
Nothing unusual happened to affect our employment or
hours figures
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Establishment Information
Using your completed Calendar Year 2005 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A), copy the establishment information into the boxes below. If these numbers are not available on your OSHA Form 300A, or if your establishment
does not keep records needed to answer (1) and (2) below, you can estimate using the steps that follow.

1. For the reporting site identified on the cover: Enter
the annual average employment for 2005. (You can
copy this from your OSHA Form 300A.)

Annual average number
of employees for 2005

2. For the reporting site identified on the cover:
Enter the total hours worked for 2005. (You can
copy this from your OSHA Form 300A.)

Total hours worked
by all employees in 2005
Note: Total Hours Worked should exclude vacation, sick leave,
holidays, and other non-work time.

If needed: Steps to estimate employment

If needed: Steps to estimate total hours worked

STEP 1: Add the number of employees your establishment paid in every pay period during 2005. Include all
employees: full-time, part-time, temporary, seasonal,
salaried, and hourly.

STEP 1: Find the number of full-time employees in your
establishment for 2005.

Acme Construction pays its employees 26 times each year.
During 2005,
Acme paid this many
employees
1 ..................................... 10
2 ..................................... 0
3 ..................................... 15

ABC Company had 15 full-time employees during 2005.

STEP 2: Multiply this number by the number of hours
worked for a full-time employee in a year. This is equal
to the number of full-time hours worked:

In this pay period

25 ................................... 15
26 ................................... 10
830 (sum)

STEP 2: Divide the sum by the number of pay periods
your establishment had in 2005. Include any pay periods when you had no employees.
Because Acme has 26 pay periods, it would divide its sum by 26.
830 divided by 26 = 31.92

STEP 3: Round the answer to the next highest whole
number. Write the rounded number in the box marked
Annual average number of employees.

ABC Company’s 15 full-time employees worked an average of about
1,760 hours each per year after excluding vacation, sick leave, holidays, and other non-work time. (The hours worked for a full-time
employee in a year may be different at your reporting site)
15 (full-time employees) times 1,760 (hours worked by a full-time
employee in a year) equals 26,400 full-time hours.

STEP 3: Add the number of any overtime hours and the
number of hours worked by other employees (part-time,
temporary, seasonal) to the amount in Step 2:
ABC Company’s full time employees worked a total of 1,500 hours
of overtime. In addition, 3 part time employees worked a total of
2,715 hours during 2005. Adding these hours to those from Step 2:
Full-time hours from Step 2
Overtime hours
Part-time hours

+
+

26,400
1,500
2,715

Total hours worked by all employees in 2005 =

30,615

Acme would round 31.92 to 32 and write that number in
the box marked Annual average number of employees.

3. Check any conditions that might have affected your annual average number of employees or total hours
worked during 2005:
Strike or lockout
Shorter work schedules or fewer pay periods than usual
Shutdown or layoff
Longer work schedules or more pay periods than usual
Seasonal work
Other reason: _____________________________________
Natural disaster or adverse weather conditions
Nothing unusual happened to affect our employment or
hours figures
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Did you have ANY occupational injuries or illnesses during 2005?
Yes. Go to the next section, Summary of Work-Related Injuries and Illnesses, 2005.
No. Go to Sign and return this form below.

Summary of Work-Related Injuries and Illnesses, 2005
Using your completed Calendar Year 2005 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A):
1. Copy the establishment summary information into the spaces below.
2. If you prefer, you may enclose a photocopy of your Summary of Work-Related Injuries and Illnesses (OSHA Form 300A).
3. If any total is zero on your OSHA Form 300A, write “0” in that total’s space below.

Number of Cases
Copy these totals
from columns
(G), (H), (I), and (J):

Total number
of cases with
days away
from work
(column H)

Total number
of deaths
(column G)

Total number
of cases with
job transfer or
restriction
(column I)

Total number
of other
recordable
cases
(column J)

Number of Days
Copy these totals
from columns (K)
and (L):

Total number
of days away
from work
(column K)

Total number of
days of job transfer
or restriction
(column L)

Injury and Illness Types
Total number of . . .
from column (M)

(1) Injuries

(4) Poisonings

(2) Skin disorders

(5) Hearing loss

(3) Respiratory conditions

(6) All other illnesses

Sign and return this form
Fill in the name, title, phone number and fax number of the person we should call with questions about this form. Then sign and
date the form.
Printed Name
Signature

(
)
Telephone Number
Title

(
)
Ext. Fax Number

E-mail address (optional)
Today’s date

➀ Remove the copy pages (3a and 4a) of this packet and return them with the Survey of Occupational Injuries and Illnesses, 2005.
The instructions in the booklet will tell you what to do.
➁ Use the envelope included with this packet to mail the original forms to us. If the return envelope is missing, send the package to
the address on the front cover. Remember to keep a photocopy for your records.

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Did you have ANY occupational injuries or illnesses during 2005?
Yes. Go to the next section, Summary of Work-Related Injuries and Illnesses, 2005.
No. Go to Sign and return this form below.

Summary of Work-Related Injuries and Illnesses, 2005
Using your completed Calendar Year 2005 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A):
1. Copy the establishment summary information into the spaces below.
2. If you prefer, you may enclose a photocopy of your Summary of Work-Related Injuries and Illnesses (OSHA Form 300A).
3. If any total is zero on your OSHA Form 300A, write “0” in that total’s space below.

Number of Cases
Copy these totals
from columns
(G), (H), (I), and (J):

Total number
of cases with
days away
from work
(column H)

Total number
of deaths
(column G)

Total number
of cases with
job transfer or
restriction
(column I)

Total number
of other
recordable
cases
(column J)

Number of Days
Copy these totals
from columns (K)
and (L):

Total number
of days away
from work
(column K)

Total number of
days of job transfer
or restriction
(column L)

Injury and Illness Types
Total number of . . .
from column (M)

(1) Injuries

(4) Poisonings

(2) Skin disorders

(5) Hearing loos

(3) Respiratory conditions

(6) All other illnesses

Sign and return this form
Fill in the name, title, phone number and fax number of the person we should call with questions about this form. Then sign and
date the form.
Printed Name
Signature

(
)
Telephone Number
Title

(
)
Ext. Fax Number

E-mail address (optional)
Today’s date

➀ Remove the copy pages (3a and 4a) of this packet and return them with the Survey of Occupational Injuries and Illnesses, 2005.
The instructions in the booklet will tell you what to do.
➁ Use the envelope included with this packet to mail the original forms to us. If the return envelope is missing, send the package to
the address on the front cover. Remember to keep a photocopy for your records.

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