Informed Consent Letter

Survey of Occupational Injuries and Illnesses Informed Consent

(state), in cooperation with the Bureau of Labor Statistics (BLS),
(industry name)
would like to publish statistical tabulations in
(Industry code, TEI). In preparing the results of the survey, however, we found that your
____ (state). Thus, publishing
company is a major reporter for your industry in
certain tabulations might permit information about your establishment to be inferred by
public users of the data. In accordance with BLS policy on confidentiality, we will not
publish those tabulations unless you provide written permission to do so.
Therefore, we request your permission to publish tabulations that might permit
information about your establishment to be inferred by the public. Space is provided at
the bottom of this page for you to provide this permission. The published tabulations
would not include your company name, address, or any other information that would
directly identify your establishment. Consent can be withdrawn at any time, but those data
published during the period of consent cannot be retracted.
We are grateful for your participation and cooperation as it is essential to the
success of our program. Safety and health professionals, employers, and the public will
gain important occupational injury and illness information that will improve the working
conditions of employees and may help decrease the occurrence of injuries and illnesses
of
in the workplace. If you have any questions, please call
(state phone number)
Office at
our
Sincerely,
(Name and Title)
__________________________________________________________________________
(company, establishment
On behalf of
(state) to publish statistical tabulations for the
name), I hereby authorize
Survey of Occupational Injuries and Illnesses in the above referenced industry.
Authorization is granted (please check one):
( ) for five consecutive Survey years (20__ through 20__);
( ) for Survey year 20__ only.
This authorization is provided solely for state publication of statistical tabulations.
Release of the information for any other purpose, or in any other manner, is neither given
nor implied.
(Signature)
(Printed Name)
(Title)

(Date)