Form CFOI-1 Census of Fatal Occupational Injuries Report

Bureau of Labor Statistics
Census of Fatal
Occupational Injuries Report

U.S. Department of Labor

This report is authorized by Public Law 91-596. The Bureau of Labor Statistics, its employees, agents, and
OMB No. 1220-0133
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 Cybersecurity Enhancement Act of
2015, Federal information systems are protected from malicious activities through cybersecurity screening of
transmitted data
ID
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: _________________________________________________________________

1. Legal name: (Please print): _________________________________________________________
(Last)
(First)
(Middle)
2. Social Security Number: ______________________
3. Direct employer at the time of the incident (company that paid deceased’s wages):
_____________________________________________________________________________
(Company name)
_____________________________________________________________________________
(Street address)
_____________________________________________________________________________
(City)
(State)
(Zip code)
(___________________)
(Area code)

BLS CFOI - 1

___________________________________________________
(Phone number)

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4. Date of birth:

________________________________________________________________
(Month)
(Day)
(Year)

5. Ethnicity and race:

(Select one or more: if unknown leave blank)

❑ American Indian or Alaska Native
❑ Black or African American
❑ Native Hawaiian or Other Pacific Islander
6. Sex: ❑ Male

❑ Asian
❑ Hispanic or Latino
❑ White

❑ Female

7. In what state did the deceased reside?

_____________________________________________

SECTION II. EMPLOYMENT INFORMATION
1. 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
2. Occupation of deceased at the time of the incident: (Examples include: cashier, drywall installer,
farm foreman) _______________________________________________________
3. How long did the deceased work in the position held at the time of the incident?
years

months (if less than 1 year)

4. 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 local government agency
❑ a State government agency

❑ a Federal government agency
❑ a foreign or international government agency
❑ other governmental body, such as a regional
or interstate commission

5. 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.)
________________________________________________________________________________

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6.

On average, about how many persons work for the establishment of the direct employer? (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
❑ Yes

If YES, where did the incident occur?

❑
❑
❑
❑

in a work area
in the company parking lot
on an outside walkway
in a recreational area

❑ in a hallway, stairway, rest room, or cafeteria
❑ some other place (Please specify):
____________________________________

❑ don’t know

6. 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:
a. 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)
___________________________________________________________________________
b. 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

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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:
1. Your name: _____________________________________________________________________
2. Your job title: ___________________________________________________________________
3. Your daytime phone number:

(__________)
(Area code)

_____________________________________
(Phone number)

4. Date you completed this form: ____________________________________________________
(Month)
(Day)
(Year)

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