U.S. Department of Labor OMB No. 1220-0045
B ureau of Labor Statistics
Survey
of Occupational Injuries
and Illnesses, 2019
YOUR RESPONSE IS REQUIRED BY LAW WITHIN 30 DAYS.
Please
correct your company address as needed.
For your convenience, you can submit your survey response
on our website at https://idcf.bls.gov.
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We estimate it will take you an average of 24 minutes to complete this survey (ranging from 10 minutes to 5 hours per package), including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing this information. If you have any comments regarding the estimates or any other aspect of this survey, including suggestions for reducing this burden, please send them to the Bureau of Labor Statistics, Occupational Safety and Health Statistics (1220-0045), 2 Massachusetts Avenue, N.E., Washington, DC 20212. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS. |
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 (44 U.S.C. 3572) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. Per the Federal Cybersecurity Enhancement Act of 2015, Federal information systems are protected from malicious activities through cybersecurity screening of transmitted data. |
BLS-9300 N06 |
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Steps to Complete this Survey
This survey requires employers to provide information about work-related injuries and illnesses based upon the information you have maintained for Calendar Year 2019 on your Occupational Safety and Health Administration (OSHA) Forms for Recording Work-Related Injuries and Illnesses. Copies of these forms were sent to you in late 2018. Under Public Law 91-596, all establishments that receive this mandatory survey must complete and return it within 30 days, even if they had no work-related injuries and illnesses during 2019. The instructions below outline the steps to complete the survey regardless of whether your establishment did or did not have injuries or illnesses in 2019.
Step 1: Complete this survey only for the establishment(s) noted on the front cover under “Report for this Location.” If you are unsure, please call the number(s) listed on the front of this form in the “For Help Call:” section.
Step 2: Check “Your Company Address” printed on the front cover. Make any necessary corrections directly on the front cover.
S
Copy
this information to Section 2 of this survey.
Copy
this information to Section 1 of this survey.
DATA
COLLECTION AGENCY Address
for Return Envelope: SURVEY
STAFF 123
MAIN STREET MY
CITY, US 12345-0000 DATA COLLECTION AGENCY SURVEY
STAFF
123
MAIN STREET MY
CITY, US 12345-0000 Your
Establishment ID: 77-123456789-3 Report
for this Location: SAME
AS YOUR COMPANY ADDRESS For
Help Call: (555)
111-2222 Your
Company Address: User
ID: YOUR
COMPANY NAME 302123456789 987
YOUR STREET YOUR
CITY, US 98765-0000 Temporary
Password: 9876Nsu 77-123456789-1 2019-1
NAICS 238000 12 P 60 00
Example
Copy
your “User ID” from the label to Section 1.
NAICS
code location.
If you had no work-related injuries or illnesses in 2019, answer all questions in Sections 1 and 4 of the survey.
If you had at least one work-related injury or illness in 2019, answer all questions in Sections 1, 2 and 4 of the survey.
Report cases with Days Away From Work (with or without days of job transfer or restriction) in Section 3.
Report cases with Job Transfer or Restriction (without days away from work) in Section 3 if you are reporting for a private industry establishment whose six-digit NAICS code begins with these numbers: 111, 336, 445, 484, 713, or 722 (see mailing label example for NAICS code location).
Step 4: In case we have questions, write the name of the person who completed this survey in Section 4: Contact Information, on the last page of this survey.
Step 5: Return this survey and any attachments in the enclosed envelope within 30 days of the date your establishment received it.
Section 1: Establishment Information
Instructions: Using your completed Calendar Year 2019 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A), copy the establishment information into the boxes. If these numbers are not available on your OSHA Form 300A, or if your establishment does not keep records needed to answer (2) and (3) below, you can estimate using the steps that follow on the next page.
1 . Enter your “User ID” from the front cover.
2 . Enter the annual average number of employees for 2019.
3 . Enter the total hours worked by all employees for 2019.
4. Check any conditions that might have affected your answers to questions 2 and 3 above during 2019:
Strike or lockout |
Shorter work schedules or fewer pay periods than usual |
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Shutdown or layoff |
Longer work schedules or more pay periods than usual |
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Seasonal work |
Other reason: _________________________________ |
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Natural disaster or adverse weather conditions |
Nothing unusual happened to affect our employment or hours figures |
5. Did you have ANY work-related injuries or illnesses during 2019?
Yes. Go to Section 2: Summary of Work-Related Injuries and Illnesses, 2019, directly below. |
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No. Go to Section 4: Contact Information, on the back cover. |
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Section 2: Summary of Work-Related Injuries and Illnesses, 2019
Instructions:
Refer to the OSHA Forms for Recording Work-Related Injuries and Illnesses for the location referenced on the front cover of the survey under “Report for this Location.” If you prefer, you may enclose a photocopy of your Summary of Work-Related Injuries and Illnesses (OSHA Form 300A).
If more than one establishment is noted on the front cover of this survey, be sure to include the OSHA Form 300A for all of the specified establishments.
If any total is zero on your OSHA Form 300A, write “0” in that total’s space below.
The total Number of Cases recorded in G + H + I + J must equal the total Injury and Illness Types recorded in
M (1 + 2 + 3 + 4 + 5 + 6).
Number of Cases |
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Total number of deaths |
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Total number of cases with days away from work |
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Total number of cases with job transfer or restriction |
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Total number of other recordable cases |
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____________________ |
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_________________ |
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_________________ |
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_________________ |
(G) |
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(H) |
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(I) |
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(J) |
Number of Days |
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Total number of days away from work |
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Total number of days of job transfer or restriction |
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____________________ |
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__________________ |
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(K) |
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(L) |
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Injury and Illness Types |
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Total number of … |
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(M) |
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(1) Injuries |
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________ |
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(4) Poisonings |
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________ |
(2) Skin disorders |
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________ |
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(5) Hearing loss |
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________ |
(3) Respiratory conditions |
________ |
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(6) All other illnesses |
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________ |
If you had any work-related deaths in 2019, please tell us on the line below where you assigned/classified each death within the list of items (M1) through (M6) provided under Injury and Illness Types above (e.g., “fatal case was due to injury resulting from fall” or “death resulted from respiratory conditions”)_________________________________
________________________________________________________________________________________________
Steps to estimate annual average number of employees for 2019:
Step 1: To calculate the annual average number of employees your establishment paid during 2019, you must calculate the total number of employees your establishment paid for all periods. Add the number of employees your establishment paid in every pay period during Calendar Year 2019. Count all employees that you paid at any time during the year and include full-time, part-time, temporary, seasonal, salaried, and hourly workers. Note that pay periods could be monthly, weekly, bi-weekly, etc. |
Example: Acme Construction paid its employees in 12 pay periods during 2019:
Pay Period Number of Employees Paid Per Pay Period
392 (total number of employees paid over all pay periods)
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Step 2: Divide the total number of employees (from Step 1) by the number of pay periods your establishment had in 2019. Be sure to count any pay periods when you had no (zero) employees. |
Example: Acme Construction had 12 pay periods and paid a total of 392 employees during these pay periods.
392 divided by 12 = 32.67
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Step 3: Round the answer you computed in Step 2 to the next highest whole number. Write that number in the box for Section 1, Question 2 on the previous page. |
Example: Acme would round 32.67 to 33. |
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Steps to estimate total hours worked by all employees for 2019:
Step 1: Determine the number of full-time employees at your establishment.
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Example: Of Acme’s 33 employees in 2019, 28 were full-time. |
Step 2: Determine the number of hours generally worked by a full-time employee for a year. Multiply the number of full-time employees you calculated in Step 1 by this number. This total number of full-time hours worked should exclude vacation, sick leave, holidays, and any other non-work time. |
Example: Each of Acme’s 28 full-time employees worked an average of 2,000 hours per year after excluding vacation, sick leave, holidays, and other non-work time. This works out to 40 hours per week for 50 weeks of the year.
28 full-time employees X 2,000 hours per year 56,000 total full-time hours
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Step 3: Determine the number of hours of overtime worked by your full-time employees.
Determine the number of regular hours worked by your non-full-time employees. (Non-full-time employees include part-time, seasonal, and temporary employees.)
Add these numbers to the number you calculated in Step 2 above. This is the estimated number of hours worked by all of your employees, full-time and non-full-time, during 2019. Write this number in Section 1, Question 3 on the previous page. |
Example: Acme’s 28 full-time employees worked a total of 2,800 hours of overtime during 2018 and 56,000 regular hours. Acme’s 5 part-time employees worked a total of 2,716 hours during 2019.
56,000 full-time hours from Step 2 2,800 over time hours + 2,716 part-time hours 61,516 total hours worked
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Section 3: Reporting Cases
Instructions:
If you had NO cases with days away from work (Column H) and NO cases with days of job transfer or restriction (Column I), please proceed to Section 4: Contact Information.
If you had cases with days away from work (Column H) and/or cases with days of job transfer or restriction only (Column I), please complete Section 3. You should report all cases with days away from work (with or without job transfer or restriction). If you are reporting for a private industry establishment whose six-digit NAICS code begins with: 111, 336, 445, 484, 713, or 722, you should also report all cases with days of job transfer or restriction (without days away from work). Your NAICS code is located on the mailing label on the front of this booklet. To identify the individual cases to report, follow these steps:
Step 1: Go to your completed OSHA Form 300.
Note
each case that has a check in Column (H) and/or Column (I).
These
are the only cases you should report.
See the illustration in
Step 3 below.
Step 2: Fill out one Injury and Illness Case Form for each case that you identified in Step 1. You can find most of the information on a supplementary document such as the Injury and Illness Incident Report (OSHA Form 301), a workers’ compensation report, an accident report, or an insurance form.
Step 3: If more than one establishment is noted on the front cover under “Report for this Location,” be sure to look at all your OSHA Form 300’s to find which cases to report.
Section
3 asks about injuries or illnesses with a check in Column H, Days
Away from Work and/or Column I, Job Transfer or Restriction, of your
Log.
Step 4: We have designed this survey to ensure that you do not have to report more than approximately 16 cases. If you have significantly more than 16 cases, please go to Section 5: If You Need Help . . . at the back of this booklet and call the phone number(s) listed for your State for assistance. If you need additional Injury and Illness Case Forms, you may either photocopy a blank form or go to Section 5: If You Need Help . . . at the back of this booklet and call the phone number(s) listed for your State.
Step 5: When you are finished, proceed to Section 4: Contact Information on the back cover of this booklet and provide information for the person who completed this survey.
Injury and Illness Case Form
Tell us about a 2019 work-related injury or illness only if it resulted in days away from work or job transfer/restriction. To find out which case(s) you should report, read the instructions at the beginning of Section 3: Reporting Cases.
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Tell us about the Case
Go to your completed OSHA Form 300. Copy the case information from that form into the spaces below.
Employee’s name (Column B)
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Job title (Column C)
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Date of injury or onset of illness (Column D)
/ /19 month day year |
Number of days away from work (Column K)
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Number of days of job transfer or restriction (Column L)
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Tell
us about the Employee 1.
Check the category
which best
describes the employee's regular type
of
job or work:
(optional)
Office,
professional, business,
Healthcare
or
management staff
Delivery
or driving
Sales
Food
service
Product
assembly,
Cleaning,
maintenance
product
manufacture
of
building, grounds
Repair,
installation or service
Material
handling
(e.g.,stocking,
of
machines, equipment
loading/unloading,
moving,
etc.)
Construction
Farming
Other:____________________ 2.
Employee’s
race or ethnic background: (optional-check
one or more)
American
Indian or Alaska Native
Asian
Black
or African American
Hispanic
or Latino
Native
Hawaiian or Other Pacific Islander
White
Not
available NOTE:
You may either answer questions (3) to (13) or attach a copy of a
supplementary document that answers them. 3.
Employee’s
age: ______
OR
date of birth: ______/______/______
month
day year
4.
Employee’s
date hired:
______/______/______
month
day year
OR
check length of service at establishment when incident occurred:
Less
than 3 months
From
3 to 11 months
From
1 to 5 years
More
than 5 years
5.
Employee’s
gender:
Male
Female
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Tell
us about the Incident Answer
the questions below or attach a copy of a supplementary document
that answers them.
Was
employee treated in an emergency room?
yes
no
Was
employee hospitalized overnight as an in-patient?
yes
no
8.
Time employee began
work: __________
am
pm
9
Check
if time cannot
be
determined Event
occurred: (optional)
before
during
after
work shift
10.
What was the
employee doing just before the incident occurred?
Describe the activity as well as the tools, equipment, or material
the employee was using. Be specific. Examples:
“climbing a ladder while carrying roofing materials”;
“spraying chlorine from hand sprayer”; “daily
computer key-entry.” 11.
What happened?
Tell us how the injury or illness occurred.
Examples:
“When ladder slipped on wet floor, worker fell 20 feet”;
“Worker was sprayed with chlorine when gasket broke during
replacement”; “Worker developed soreness in wrist over
time.” 12.
What was the injury
or illness? Tell
us the part of the body that
was
affected and how it was affected; be more specific than “hurt,”
“pain,”
or “sore.” Examples:
“strained back”; “chemical burn,
hand”;
“carpal tunnel syndrome.” 13.
What object or
substance directly harmed the employee?
Examples:
“concrete floor”; “chlorine”; “radial
arm saw.” If this
question
does not apply to the incident, leave it blank.
N
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P |
S |
E |
SS |
OCC |
Injury and Illness Case Form
Tell us about a 2019 work-related injury or illness only if it resulted in days away from work or job transfer/restriction. To find out which case(s) you should report, read the instructions at the beginning of Section 3: Reporting Cases.
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Tell us about the Case
Go to your completed OSHA Form 300. Copy the case information from that form into the spaces below.
Employee’s name (Column B)
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Job title (Column C)
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Date of injury or onset of illness (Column D)
/ /19 month day year |
Number of days away from work (Column K)
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Number of days of job transfer or restriction (Column L)
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Tell
us about the Employee 1.
Check the category
which best
describes the employee's regular type
of
job or work:
(optional)
Office,
professional, business,
Healthcare
or
management staff
Delivery
or driving
Sales
Food
service
Product
assembly,
Cleaning,
maintenance
product
manufacture
of
building, grounds
Repair,
installation or service
Material
handling
(e.g.,stocking,
of
machines, equipment
loading/unloading,
moving,
etc.)
Construction
Farming
Other:____________________ 2.
Employee’s
race or ethnic background: (optional-check
one or more)
American
Indian or Alaska Native
Asian
Black
or African American
Hispanic
or Latino
Native
Hawaiian or Other Pacific Islander
White
Not
available NOTE:
You may either answer questions (3) to (13) or attach a copy of a
supplementary document that answers them. 3.
Employee’s
age: ______
OR
date of birth: ______/______/______
month
day year
4.
Employee’s
date hired:
______/______/______
month
day year
OR
check length of service at establishment when incident occurred:
Less
than 3 months
From
3 to 11 months
From
1 to 5 years
More
than 5 years
5.
Employee’s
gender:
Male
Female
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Tell
us about the Incident Answer
the questions below or attach a copy of a supplementary document
that answers them.
Was
employee treated in an emergency room?
yes
no
Was
employee hospitalized overnight as an in-patient?
yes
no
8.
Time employee began
work: __________
am
pm
9
Check
if time cannot
be
determined Event
occurred: (optional)
before
during
after
work shift
10.
What was the
employee doing just before the incident occurred?
Describe the activity as well as the tools, equipment, or material
the employee was using. Be specific. Examples:
“climbing a ladder while carrying roofing materials”;
“spraying chlorine from hand sprayer”; “daily
computer key-entry.” 11.
What happened?
Tell us how the injury or illness occurred.
Examples:
“When ladder slipped on wet floor, worker fell 20 feet”;
“Worker was sprayed with chlorine when gasket broke during
replacement”; “Worker developed soreness in wrist over
time.” 12.
What was the injury
or illness? Tell
us the part of the body that
was
affected and how it was affected; be more specific than “hurt,”
“pain,”
or “sore.” Examples:
“strained back”; “chemical burn,
hand”;
“carpal tunnel syndrome.” 13.
What object or
substance directly harmed the employee?
Examples:
“concrete floor”; “chlorine”; “radial
arm saw.” If this
question
does not apply to the incident, leave it blank.
N
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P |
S |
E |
SS |
OCC |
Section 4: Contact Information
Fill in the name, title, and phone number of the person who completed this survey in case we have questions.
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( ) - |
Printed name Telephone number Ext. Fax number
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Title Today’s date
Use the return envelope to send us the entire package – everything that we sent you – within 30 days of the date your establishment received it. If the return envelope is missing, send the entire package to the return address on the front cover (look for Address for Return Envelope).
Section 5: If You Need Help . . .
If you have any questions or if you need help completing this survey, call the phone number(s) that is listed below for your State. The phone number(s) may be for an office outside your State, but they will be able to help you. If you prefer to write, send your letter to the return address on the front of this package.
Alabama
(334) 956-7440, 7444
(334) 956-7467, 7442
(334) 956-7492 fax
Alaska
(907) 465-6034
(907) 465-4506 fax
Arizona
(602) 542-3739
(602) 542-6360 fax
Arkansas
(501) 682-4509
(501) 682-4754 fax
California
(415) 703-3020
(415) 703-3029 fax
Colorado
(972) 850-4812
(816) 285-7031
(972) 850-4810 fax
Connecticut
(860) 263-6272
(860) 263-6263 fax
Delaware
(302) 761-8221
(302) 762-3590 fax
District of Columbia
(202) 442-9010, 5930, 5926
(202) 442-4833 fax
Florida
(215) 861-5628, 5637
(215) 861-5736 fax
Georgia
(404) 656-7089
(404) 463-0737, 0753, 0738
(404) 656-5529 fax
Guam
(671) 300-6339
(671) 475-7063 fax
Hawaii
(808) 586-9001
(808) 586-9022 fax
Idaho
(415) 625-2275, 2267
(415) 625-2294 fax
Illinois
(217) 524-2098
(217) 558-4122 fax
Indiana
(317) 232-2668
(317) 233-3790 fax
Iowa
(515) 725-5611
(515) 725-7924 fax
Kansas
(785) 581-7479
(785) 296-2151 fax
Kentucky
(502) 564- 4105, 4259
(502) 564- 4137, 4125
(502) 564-0539 fax
Louisiana
(225) 342-3126
(225) 342-3269 fax
Maine
(207) 623-7903
(207) 623-7937 fax
Maryland
(410) 527-4460, 4461, 4462
(410) 527-4497 fax
Massachusetts
(617) 626-6945
(617) 626-6944 fax
Michigan
(517) 284-7788
(517) 284-7815 fax
Minnesota
(888) 589-6322
(651) 284-5726 fax
Mississippi
(404) 893-1934, 8344
(404) 893-8343 fax
Missouri
(573) 751-3802, 2719
(573) 751-2319 fax
Montana
(406) 444-3297
(406) 444-4140 fax
Nebraska
(402) 471-3547, 1545
(800) 599-5155
(402) 471-6523 fax
Nevada
(866) 931-1215
(702)
486-9197, 9187
(702) 486-9175 fax
New Hampshire
(617) 565-2302
(617) 565-3847 fax
New Jersey
(609) 292-8999
(609) 633-0618 fax
New Mexico
(505) 476-8740
(505) 476-8735 fax
New York
(888)
425-1323
(888) 807-0410 fax
North Carolina
(919) 707-7765
(919) 733-2186 fax
North Dakota
(312) 353-7253
(312) 353-7230 fax
Ohio
(866) 569-7806
(614) 995-8608
(614) 728-6460 fax
Oklahoma
(312) 353-7253
(312) 353-7230 fax
Oregon
(503) 947-7030
(503) 947-7312 fax
Pennsylvania
(800) 238-9412
(717) 705-4318 fax
Puerto Rico
(787) 754-5300, ext. 3032, 3036, 3051, 3056, 3057
(787) 754-5360 fax
Rhode Island
(617) 565-2302
(617) 565-3847 fax
South Carolina
(803) 896-7659, 7683
(803) 896-7670 fax
South Dakota
(312) 353-7253
(312) 353-7230 fax
Tennessee
(615) 741-1748
(800) 778-3966
(615) 253-5501 fax
Texas
(866) 237-6405
(512) 804-4652 fax
Utah
(801) 530-6926, 6823
(801) 536-7906 fax
Vermont
(802) 828-4153
(802) 828-4050 fax
Virgin Islands
(340) 776-3700 ext. 2019
(340) 715-5740 fax
Virginia
(804) 786-1995
(804) 786-2376 fax
Washington
(360) 902-5640
(360) 902-4249 fax
West Virginia
(304) 558-0212 ext. 3054
(304) 558-1343 fax
Wisconsin
(800) 884-1273
(608)-221-6293
(608) 221-6297 fax
Wyoming
(866) 518-6680
(307) 473-3838
(307) 473-3863 fax
File Type | application/msword |
File Title | Survey of Occupational Injuries |
Author | kurlick_g |
Last Modified By | SYSTEM |
File Modified | 2019-08-21 |
File Created | 2019-08-21 |