Download:
pdf |
pdfU.S. Department of Labor, Bureau of Labor Statistics
OMB No. 1220-0045
Survey of Occupational Injuries
and Illnesses, 2019
Fax Response Form
Fax to Number listed on the Front of your Survey Instructions
Employers selected for the BLS Survey of Occupational Injuries and Illnesses are required by Federal Law to respond.
If you have questions please contact us at the phone number listed on the front of your survey instructions.
Section 1: Establishment Information
- 12345678901234567890 - 10
Establishment ID Number (from front of survey instructions)
Company Name and Report For (from front of survey instructions)
Contact Name and Title (please print)
Today’s Date
Telephone Number (ext)
(
)
-
(
)
Fax Number
-
1 Enter the annual average number of employees for 2019.
2. Enter the total hours worked by all employees for 2019.
3. Did you have ANY work-related injuries or illnesses during 2019?
Yes
Complete Section 2 below.
No
Please fax this form to the fax number listed on the front of your survey instructions.
Section 2: Summary of Work-Related Injuries and Illnesses
1. Refer to the OSHA Forms for Recording Work-Related Injuries and Illnesses for the location referenced on the front
of the survey instructions under Report For.
2. If you prefer, you may fax your Summary of Work-Related Injuries and Illnesses (OSHA Form 300A) with this form. If more
than one establishment is noted on the front of the survey instructions, be sure to fax the OSHA Form 300A for each of the
specified establishments.
3. If any total is zero on your OSHA Form 300A, write “0” in that space below.
4. 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
Total number of deaths
____________________
(G)
Number of Days
Total number of cases
with days away from
work
Total number of cases
with job transfer or
restriction
_________________
(H)
_________________
(I)
Total number of days
away from work
Total number of days
of job transfer or
restriction
____________________
(K)
__________________
(L)
Injury and Illness Types
Total number of …
(M)
(1) Injuries
(2) Skin disorders
(3) Respiratory conditions
________
________
________
(4) Poisonings
(5) Hearing loss
(6) All other illnesses
Total number of other
recordable cases
_________________
(J)
________
________
________
BLS-9300 FAX
Injury and Illness Case Form
Tell us about each 2019 work-related injury or illness case if it resulted in days away from work (Column H in Section 2 on Page 1). If
you are reporting for a private industry establishment whose six-digit NAICS code begins with: 111, 336, 445, 484, 713, or 722, also
tell us about each case with days of job transfer or restriction (Column I in Section 2 on Page 1). Your NAICS code can be found on
the front of your survey instruction sheet. One Injury and Illness Case Form should be completed for each injury or illness case.
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)
Date of injury
or
onset of illness
(Column D)
Job title
(Column C)
/
month
Number of days
away from work
(Column K)
Number of days
of job transfer
or restriction
(Column L)
/19
day
year
Tell us about the Employee
Tell us about the Incident
1. Check the category which best describes the employee's regular type
of job or work: (optional)
Answer the questions below or attach a copy of a supplementary
document that answers them.
Office, professional, business,
or management staff
Sales
Product assembly,
product manufacture
Repair, installation or service
of machines, equipment
Construction
Other:____________________
Healthcare
Delivery or driving
Food service
Cleaning, maintenance
of building, grounds
Material handling (e.g.,stocking,
6. Was employee treated in an emergency room? yes
no
7. Was employee hospitalized overnight as an in-patient? yes no
8. Time employee began work: __________ am pm
9. Time of event: __________ am pm OR Check if time cannot
be determined
Event occurred: (optional) before during after work shift
loading/unloading, moving, etc.)
Farming
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.”
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
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.”
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
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.”
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
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.
5. Employee’s gender:
Male
Female
Thank you for your participation. Please fax completed forms to fax number on front of your survey instructions.
For office use
N
P
S
E
SS
OCC
File Type | application/pdf |
File Title | Survey of Occupational Injuries |
Author | mccarthy_w |
File Modified | 2020-01-29 |
File Created | 2020-01-29 |