Attachments

CFOI OMB 070913 - Attachments 2013.doc

Census of Fatal Occupational Injuries

Attachments

OMB: 1220-0133

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Attachment 1A

Census of Fatal Occupational Injuries

Data Elements

(Collected and Coded by States, Cities, and Territories)

Reference State and year
Injury or illness
State of residence
Date of birth
Age, Source document associated with age
Race, Source document associated with race
Hispanic or Latino origin, Source document associated with Hispanic or Latino Origin
Gender, Source document associated with gender
Industry code and narrative (North American Industrial Classification System (NAICS)), Source document associated with industry
Ownership (Federal, State, local, foreign, or other government; or private sector), Source document associated with ownership
Establishment size class
Occupation code and narrative (Standard Occupational Classification (SOC)), Source document associated with occupation

Employee status (Active duty military, self-employed, family business, working for pay, volunteer, institutionalized individuals, unknown), Source document associated with employee status

State of employment
Date of injury and death
State of injury and death
County of injury
Time of incident
Nature of injury/illness (BLS Occupational Injury and Illness Classification System (OIICS))
Part of body (BLS OIICS)
Primary and secondary source of injury/illness (BLS OIICS)
Event or exposure (BLS OIICS), Source document associated with event or exposure
Worker activity
Location type (farm, street, mine, etc.)
How the injury/illness occurred (narrative description; up to 500 characters)
Source documents requested and received
Link code (links fatalities resulting from a single incident)
Birthplace—country
Medical complications code
Impairments
Contractor information (whether worker was employed by a contractor and contracting agency’s industry code, industry narrative, and ownership)*

Optional data elements

Length of time in occupation**/current position/with employer**
Usual lifetime industry/occupation**
Time workday began, Time of incident before time workday began*
Cause of injury/illness (ICD-10 external cause codes)**

Processing comments
Union status (whether worker was a member of a union)*
Confined space incident (whether worker was in a confined space)*
Alcohol/drug, narrative (whether the decedent was under the influence of drugs or alcohol, and which ones specifically)*
Disaster codes (whether the death was a result of a CFOI-designated disaster)*
Seat belt (whether decedent was wearing a seat belt)*

*Added beginning with data for 2011

**Deleted beginning with data for 2011

Attachment 1B

Census of Fatal Occupational Injuries

Research File Data Elements

The following data elements are included on the CFOI Research File for each fatality record. This file is given to qualified researchers who sign a Letter of Agreement and agree to comply with BLS confidentiality policy.

Year of death
Region designation for State code
Report ID (unique 5-digit code)
Injury (illnesses are maintained as a separate file)
Race
Gender
Industry (based on the Standard Industrial Classification (SIC) Manual /
North American Industrial Classification System beginning with data for 2003)
Ownership (federal, state or local government; private)
Occupation (based on the 1990 Census of Population Occupational Classification System /
Standard Occupation Classification (SOC) beginning with 2003 data)
Employee status (wage and salary, self-employed, etc.)
Nature of injury/illness (based on the BLS Occupational Injury and Illness
Classification Structures (OIICS), which was adopted as a National standard by ANSI Z16.2 in September 1995.
Part of body affected (BLS OIICS)
Source of injury (BLS OIICS)
Secondary source of injury (BLS OIICS)
Event or exposure (BLS OIICS)
Worker activity (at the time of incident)
Hispanic origin
Location of incident (farm, street, mine, etc.)
Age (10-year intervals starting with less than 20)
Date of injury (day of the week, month, and year)
Days survived (number of days between injury and death)
Born in foreign country (name of continent)
Establishment sizes (5 employment size groups)
Length of time with employer (in years)
Urban or rural area
Time of incident (to the nearest hour)
How the injury occurred (narrative description up to 500 characters)
Confined space incident*
Contractor information (whether worker was employed by a contractor and contracting agency’s industry code, industry narrative, and ownership)*

Additional data elements requested by NIOSH:

State codes
Date of birth
Date of death
Death certificate identification number
Narrative industry and occupation description

*Added beginning with data for 2011

Followback questionnaire: Informant letter (CFOI-1) Attachment 2A

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State letterhead

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Dear:

It is with sincere regret that we must request your assistance during this difficult time. We have learned of [decedent's name]'s death and that it may have occurred at work. We request your assistance in providing information that will help us to better understand the circumstances surrounding the incident. Please take a few minutes to complete this important information using the enclosed form.

What we are asking:

We are committed to minimizing your effort in providing the requested information. Therefore, we have completed all of the information that is available to us. To ensure accuracy and completeness of information, we request that you:

check our entries and make any necessary corrections to the information reported;
complete any missing information that you have available; and
indicate which, if any, information you are unable to provide by writing in ‘NA.’

If you prefer, you may provide the requested information by telephone. Information about whom to contact is provided below.

Reason for our request:

The purpose of this request is to obtain a better understanding of the hazards employees face in the workplace. Complete and accurate information on work-related injuries and fatalities is essential for developing effective strategies that may reduce the number of work-related injuries.

Authorizations for collecting information:

The information is being collected by the [State Agency] in cooperation with the Bureau of Labor Statistics of the U.S. Department of Labor. The Census of Fatal Occupational Injuries is authorized by the Occupational Safety and Health Act of 1970 (Public Law 91-596) and has been approved by the Office of Management and Budget (OMB Number 1220-0133).

Confidentiality of your information:

Your voluntary cooperation is needed to ensure the information we collect is complete and accurate. The Bureau of Labor Statistics, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent.

Summary results will be made public to inform workers and employers about hazards in the workplace. Under written agreements to protect confidentiality and security of identifying information, a detailed data file will be made available to authorized researchers for conducting specific research projects. No personal or company identifiers will be released. Although we have taken every precaution to ensure the confidentiality of the information that you provide, it may be possible to recognize catastrophic or well-publicized events from the BLS releases.

To return your completed form:

We have enclosed an envelope to assist you in returning the form as soon as possible. If you have any questions about the form or would like to report the information by telephone, please contact [name and telephone number to be inserted by the individual State].

Thank you very much in advance for your assistance in providing valuable information that will help make workplaces safer.

With deepest sympathy,

[State agency official]

Enclosures

Followback questionnaire: Letter for Employer or Administrative Agency (CFOI-1)

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State letterhead

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Dear:

We have learned of [decedent's name]'s death and that it may have occurred at work. We request your assistance in providing information that will help us to better understand the circumstances surrounding the incident. Please take a few minutes to complete this important information using the enclosed form or by sending us a copy of the report describing the incident.

What we are asking:

check our entries and make any necessary corrections to the information reported;
complete any missing information that you have available; and
indicate which, if any, information you are unable to provide by writing in ‘NA.’

If you prefer, you may provide the requested information by telephone. Information about whom to contact is provided below.

Reason for our request:

Authorizations for collecting information:

Confidentiality of your information:

To return your completed form:

Thank you very much in advance for your assistance in providing valuable information that will help make workplaces safer.

Sincerely,

[State agency official]

Enclosures

Bureau of Labor Statistics U.S. Department of Labor

Census of Fatal
Occupational Injuries Report

This report is authorized by Public Law 91-596. The Bureau of Labor Statistics, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent.

OMB No. 1220-0133

Public Burden Statement: Your voluntary cooperation is needed to make the results of this study comprehensive, accurate, and timely. The Bureau estimates that it will take from 10 to 30 minutes to complete this form, with an average of 20 minutes, including time for gathering the information needed and completing the form. If you have any comments regarding this estimate or any other aspect of this data collection, including suggestions for reducing this burden, you may send them to the Bureau of Labor Statistics, CFOI Program, 2 Massachusetts Avenue, NE, Room 3180, Washington, DC 20212-0001. Do not send the completed form to this address. You do not have to complete this form if it does not display a currently valid OMB Control Number.

Return to:

For assistance call:

Instructions: Some information about the incident is already provided on this form. Please review this information and do the following:

Correct any inaccurate information.

Add any missing information.

If you cannot answer a question, please indicate that you do NOT have sufficient

information to answer the question.

Please contact us if you have any questions regarding this form.

SECTION I. DECEASED WORKER AND EMPLOYER

NAME: _________________________________________________________________

Legal name: (Please print): _________________________________________________________
(Last) (First) (Middle)

Social Security Number: ______________________

Direct employer at the time of the incident (company that paid deceased’s wages):

_____________________________________________________________________________

(Company name)

_____________________________________________________________________________

(Street address)

_____________________________________________________________________________

(City) (State) (Zip code)

(___________________) ___________________________________________________

(Area code) (Phone number)

BLS CFOI - 1

___ ____

ST ID

Date of birth: ________________________________________________________________

(Month) (Day) (Year)

Ethnicity and race: (Select one or more: if unknown leave blank)

 American Indian or Alaska Native  Asian

 Black or African American  Hispanic or Latino

 Native Hawaiian or Other Pacific Islander  White

Gender:  Male  Female

In what state did the deceased reside? _____________________________________________

SECTION II. EMPLOYMENT INFORMATION

Which of the following BEST describes the deceased's employment status at the time of

the incident? (Check only ONE)

 Active duty, Armed Forces

 Self-employed, partner, or owner of a business, farm, or professional practice

(Check only ONE:  incorporated  unincorporated )

 Working for the family business, except owner (includes paid or unpaid work)

 Working for pay or other compensation (such as room and board) in other than the family business

 Working as a volunteer without pay or other compensation

 Other (Please specify:) _________________________________________________________

 Don't know

Occupation of deceased at the time of the incident: (Examples include: cashier, drywall installer,
farm foreman) _______________________________________________________

How long did the deceased work in the position held at the time of the incident?

years months (if less than 1 year)

Which of the following best describes the type of employer the deceased was directly employed by? (Check only ONE)

 a private company or self-employed  a Federal government agency

 a local government agency  a foreign or international government agency

 a State government agency  other governmental body, such as a regional

or interstate commission

Describe the nature of the business or the main type of activity performed by the direct employer at the establishment. (Examples include: manufacturer of storage batteries, grocery store, computer programming services, etc.)

________________________________________________________________________________

___ ____

ST ID

On average, about how many persons work for the direct employer at the actual location or

worksite where the incident occurred? (Check only ONE)

 1-10  11-19  20-49  50-99  100 or more  don't know

SECTION III. INFORMATION ABOUT THE INCIDENT

1. Date of death: ___________________________________________________________________

(Month) (Day) (Year)

2. State in which death occurred: _____________________________________________________

3. Date the incident occurred: ________________________________________________________

(Month) (Day) (Year)

4. Where did this incident occur?

State: _______________________________________________________________________

County: _____________________________________________________________________

Type of location (Examples include: farm, highway, bank, etc.):
_____________________________________________________________________

5. Did the incident occur on the direct employer's premises?

No
Y es If YES, where did the incident occur?

 in a work area  in a hallway, stairway, rest room, or cafeteria

 in the company parking lot  some other place (Please specify):

 on an outside walkway ____________________________________

 in a recreational area  don’t know

Was the site where the employee was working at the time of the incident under the control of his/her direct employer, or was the employee working at a site where a different company exercised overall responsibility for the operations at the site?

 Direct employer

 Different company If different company:

Describe the nature of the business or the main type of activity performed by this different company at the establishment. (For example, a plumber for a repair firm was killed while working at a restaurant to fix a dishwasher. The direct employer is the repair firm since it paid the plumber’s wages. The different company is the restaurant since it exercised overall responsibility for the operations at the site)

___________________________________________________________________________

Which of the following best describes the type of employer this different company is? (Check only ONE)

 a private company  a Federal government agency

 a local government agency  a foreign or international government agency

 a State government agency  other governmental body, such as a regional

or interstate commission

___ ____

ST ID

7. What was the deceased doing at the time of the incident? (Mark ALL that apply.)

 normal commute between home and usual work location

 job-related errand or travel other than commuting to or from work

 attending training provided or required by the employer

 routine or typical work activity (Please specify): ___________________________________

 other activity on the employer premises

work-related activity (Please specify): ___________________________________________
non-work-related activity (Please specify): _______________________________________

 non-work-related personal business

 don't know

8 . What time did the incident occur? Check only ONE:  AM  PM

9 . What time did the deceased's workday

begin on the day the incident occurred? Check only ONE:  AM  PM

10. The injury/illness resulted from: (Check the MOST accurate statement.)

 an incident, such as a fall, explosion, shooting, etc.

 an exposure to a chemical, substance, or environmental factor lasting a day or less

 an exposure to a chemical, substance, or environmental factor lasting more than a day

 heart attack/stroke

 natural causes other than heart attack or stroke

 other (Please specify): ____________________________________________________

11. Please provide more specific details to describe the injury/illness and the events which

resulted in the injury/illness:

a. Include information about how the injury/illness occurred.

b. Identify any equipment, objects, or substances involved in the incident and describe

how they were involved. (Please use additional pages if more space is needed.)

_______________________________________________________________________________

SECTION IV. RESPONDENT IDENTIFICATION

Please provide the following information:

Your name: _____________________________________________________________________

Your job title: ___________________________________________________________________
Your daytime phone number: (__________) _____________________________________

(Area code) (Phone number)

Date you completed this form: ____________________________________________________

(Month) (Day) (Year)

Letter requesting source documents

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State letterhead

---------------------------------------------------------------------------------------------------------------------

Dear:

The Occupational Safety and Health Act of 1970 (PL 91-596) requires the Secretary of Labor to develop and maintain an effective program of collection, compilation, and analysis of occupational safety and health statistics. In response to the need for complete, accurate, and timely data for occupational fatalities occurring in the United States, the Bureau of Labor Statistics (BLS), in cooperation with (State Agency), implemented the Census of Fatal Occupational Injuries (CFOI) in 1992. The CFOI has been approved by the Office of Management and Budget (OMB Number 1220-0133).

To ensure complete, up-to-date fatality information, we collect data from various sources:

death certificates;
Federal and State workers’ compensation reports;
reports to Federal and State regulatory agencies;
medical examiner and autopsy reports;
highway and police reports; and
other reports available to State agencies.

We would appreciate your assistance in collecting these data. We would like to receive, on a flow basis, copies of any documents or reports you receive concerning work-related fatalities. We may also request documents for fatalities identified by other sources as work-related to obtain additional information. We will use information contained on these documents to determine if the fatality occurred while the person was in a work status. The worker’s name, Social Security Number, date of birth, date of injury, date of death, and employer’s name are needed to match reports from other sources to ensure that each fatality is counted only once.

Summary results will be made public to inform workers and employers about hazards in the workplace. Under written agreements to protect confidentiality and security of identifying information, a detailed data file will be made available to authorized researchers for conducting specific research projects. No personal or company identifiers will be released. Although we have taken every precaution to ensure the security of information collected under a pledge of confidentiality, it may be possible to recognize catastrophic or well-publicized events from the BLS releases.

[We would like to meet with you at your convenience to discuss this program in more detail.] Please call (State contact name) at (telephone number) if you have any questions regarding the fatality census or would like to schedule an appointment with us. If a more formal arrangement is needed to obtain these documents, please let us know and we would be happy to discuss the options with you, including a Memorandum of Understanding between our agencies.

Sincerely yours,

(State official’s name)

FAX requesting death certificates

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State letterhead

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FAX TRANSMISSION

**********************************************************************

This document and any attachments are confidential and intended solely
for the individual or entity to whom they are addressed. If you have
received this fax in error, destroy it immediately.

**********************************************************************

Date:

Please deliver to: [Name, address, fax, and phone]

Total number of pages including this sheet: __________

Please fax or mail Death Certificates for the persons listed below to:

[ Name, address, fax, and phone of CFOI state agency ]

Thank you for your time.

[Name of CFOI contact]

Name SS# Date of death

John Doe xxx-yy-zzzz mm/dd/yyyy

Jane Smith yyy-xx-aaaa mm/dd/yyyy

End of list

File Type	application/msword
File Title	Attachment 2A
Author	OCWC
Last Modified By	kincaid_n
File Modified	2013-07-17
File Created	2013-07-17