BLS 9300 FAX SOII FAX form

U.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
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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

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