Form BLS-9300 Survey of Occupational Injuries and Illnesses

S urvey of Occupational Injuries
and Illnesses, 2004

U.S. Department of Labor

Bureau of Labor Statistics

Please correct your company address as needed

Dear Employer:

This survey asks employers to provide information about occupational injuries and illnesses based upon the information you have maintained for Calendar Year 2004 on your OSHA Forms for Recording Work-Related Injuries and Illnesses. Copies of these forms were mailed to you in late 2003. Although participation in this survey is mandatory under Public Law 91-596, we have made every effort to reduce the amount of time required wherever possible and still collect the necessary information. To the full extent permitted by law, this information will be held in confidence and be used only for statistical purposes. Contact information is included for each State to provide you with assistance in completing this survey.

For your convenience, you can submit your survey response online at https://idcf.bls.gov

Bureau of Labor Statistics

U.S. Department of Labor

N

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 of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent.

OMB No. 1220-0045 BLS-9300 N06

Who must complete the Survey of Occupational Injuries and Illnesses?

Under Public Law 91-596, all establishments that receive this survey must complete and return it within 30 days, even if they had no work-related injuries and illnesses during 2004.

What do you need to do?

• Identify the Reporting Site referred to on the front cover. Complete this survey only for the establishment(s) noted on the front cover under Reporting Site.

• Check Your Company Address printed on the front cover. Make any necessary corrections directly on the front cover.

• Refer to your Reporting Site’s OSHA Forms for Recording Work-Related Injuries and Illnesses. Copies of these forms were mailed to you in late 2003.

• your 2004 Log of Work-Related Injuries and Illnesses (OSHA Form 300),

• your 2004 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A), and

• your supplemental records of cases with days away from work (OSHA Form 301 or an equivalent).

• Complete Part 1A and Part 1B. You can either photocopy your OSHA Form 300A or you can transcribe the entries noted below from your OSHA Form 300A to this survey form.

Copy this information to Part 1B of this survey form.

Copy this information to Part 1A of this survey form.

• Complete Part 2: Reporting Cases with Days Away from Work if your establishment had any worker injuries or illnesses that resulted in days away from work in 2004.

• Write the name of the contact person we should call with questions in Contact Information on the back cover of this booklet.

• Return this survey booklet and any attachments in the enclosed envelope within 30 days of the date your establishment received it.

Part 1A. Establishment Information

Using your completed Calendar Year 2004 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A), copy the establishment information into the boxes below. If more than one establishment is noted on the front cover under Reporting Site, add together the total lines from each specified establishment’s OSHA Form 300A to complete the 2004 totals for all establishments. Then copy those totals into the corresponding spaces below. If these numbers are not available on your OSHA Form 300A, or if your establishment does not keep records needed to answer (1) and (2) below, you can estimate using the steps that follow.

1. For the reporting site identified on the cover:

Enter the annual average employment for 2004.

(You can copy this from your OSHA Form 300A.)

Annual average number
of employees for 2004

If needed: Steps to estimate employment

If needed: Steps to estimate total hours worked

STEP 1: Add the number of employees your establishment paid in every pay period during 2004. Include all employees: full-time, part-time, temporary, seasonal, salaried, and hourly.

STEP 1: Find the number of full-time employees in
your establishment for 2004.

Acme Construction pays its employees 26 times each year. During 2004,

In this pay period Acme paid this many employees

1 ............................…....……..10

2 ...…...............…………....... 0

3 ......................…….……...... 15

 

25............................….……..... 15

26..…..................…………...... 10

830 (sum)

STEP 2: Divide the sum by the number of pay periods your establishment had in 2004. Include any pay periods when you had no employees.

Because Acme has 26 pay periods, it would divide

its sum by 26. 830 divided by 26 = 31.92

STEP 3: Round the answer to the next highest whole number. Write the rounded number in the box marked Annual average number of employees.

Acme would round 31.92 to 32 and write that number in the box marked Annual average number of employees.

2. For the reporting site identified on the cover:

Enter the total hours worked for 2004.

(You can copy this from your OSHA Form 300A.)

Total hours worked
by all employees in 2004

Note: Total Hours Worked should exclude vacation, sick leave, holidays, and other non-work time.

ABC Company had 15 full-time employees during 2004.

STEP 2: Multiply this number by the number of hours worked for a full-time employee in a year. This is equal to the number of full-time hours worked:

ABC Company’s 15 full-time employees worked an average of about 1,760 hours each per year after excluding vacation, sick leave, holidays, and other non-work time. (The hours worked for a full-time employee in a year may be different at your reporting site.)

STEP 3: Add the number of any overtime hours and the number of hours worked by other employees (part-time, temporary, seasonal) to the amount in Step 2:

15 (full-time employees) times 1,760 (hours worked by a full-time employee in a year) equals 26,400 full-time hours.

ABC Company’s full-time employees worked a total of 1,500 hours of overtime. In addition, 3 part-time employees worked a total of 2,715 hours during 2004. Adding these hours to those from Step 2:

Full-time hours from Step 2 26,400

Overtime hours + 1,500

Part-time hours + 2,715

Total hours worked by all
employees in 2004 = 30,615

3. Check any conditions that might have affected your annual average number of employees or total hours worked during 2004:

 Strike or lockout	 Shorter work schedules or fewer pay periods than usual
 Shutdown or layoff	 Longer work schedules or more pay periods than usual
 Seasonal work	 Other reason: _____________________________________
 Natural disaster or adverse weather conditions	 Nothing unusual happened to affect our employment or hours figures.

Did you have ANY occupational injuries or illnesses during 2004?

 Yes. Go to Part 1B: Summary of Work-Related Injuries and Illnesses, 2004 directly below.

 No. Go to Contact Information on the back cover.

Part 1B: Summary of Work-Related Injuries and Illnesses, 2004

Using your completed Calendar Year 2004 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A):

• Copy the establishment summary information into the spaces below. If more than one establishment is noted on the
  front cover under Reporting Site, add together the total lines from each specified establishment’s OSHA Form 300A
  to complete the 2004 totals for all establishments. Then copy those totals into the corresponding spaces below.

• 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 under Reporting Site, 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.

Number of Cases

	Total number of deaths	Total number of cases with days away from work	Total number of cases with job transfer or restriction	Total number of other recordable cases
	_____________	(H)	____________	___________
	(G)		(I)	(J)

Number of Days

	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		______	(4) Poisonings	______
(2) Skin disorders		______	(5) Hearing loss	______
(3) Respiratory conditions		______	(6) All other illnesses	______

• The total Number of Cases recorded above in G + H + I + J must equal the total Injury and Illness Types recorded above
  in M (1 + 2 + 3 + 4 + 5 + 6).

• If you had any work-related deaths in 2004, please tell us where you assigned/classified each death within the list of
  items (M1) through (M6) provided under section Injury and Illness Type above (e.g., “fatal case was due to injury resulting from fall” or “death resulted from respiratory conditions”).

____________________________________________________________________________________

Before you continue…

Look at the total Number of Cases you entered in Column H above.

• If you had NO cases in Column H, you are finished with the survey. Go to Contact Information on the Back Cover.

• If you had cases in Column H, go to Part 2: Reporting Cases with Days Away from Work.

Part 2: Reporting Cases with Days Away from Work

This part of the survey asks you about individual injuries and illnesses that resulted in an employee being away from work. Several copies of the form Case with Days Away from Work are included. To answer the questions on this form, you'll need:

• your completed copy of the 2004 Log (OSHA Form 300)

Part 2 asks about injuries

or illnesses with a check

in Column H of your Log.

• your completed copies of supplementary documents about the case, such as a workers' compensation report, an accident report, an insurance form, or the Injury and Illness Incident Report (OSHA Form 301).

Which cases should you report?

To identify the individual cases to report, follow these steps:

• Go to your completed 2004 OSHA Form 300. If more than one establishment is noted on the front cover under Reporting Site, be sure to look at all your OSHA Form 300’s to find which cases to report.

• Mark each case that has a check in column (H) on the
  Log (OSHA Form 300). These are the only cases you
  should report.

• We have designed this survey to ensure that you do not have to report more than approximately 30 cases. If you have significantly more than 30 cases, please go to If You Need Help . . . at the back
  of this booklet and call the phone number listed for your State for assistance.

• Fill out one Case with Days Away from Work form for each case that you identified in Step .
  You can find most of the information on a supplementary document such as a workers'
  compensation report, an accident report, an insurance form, or the Injury and Illness Incident
  Report (OSHA Form 301).
  
  (If you need more Case with Days Away from Work forms, you may either photocopy a blank one
  or go to If You Need Help . . . at the back of this booklet and call the phone number listed for your State).

• When you have finished, proceed to Contact Information on the back cover of this booklet.

Case with Days Away from Work

Tell us about a 2004 occupational injury or illness only if it resulted in days away from work. To find out which case(s) you should report, read the instructions at the beginning of Part 2: Reporting Cases with Days Away from Work.

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)      	Job title (column C)      	Date of injury or onset of illness (column D)    /    /04 month day year	Number of days away from work (column K)      	Number of days of job transfer or restriction (column L)      

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 (11) 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 sex:

_ Male

_ Female

^{Tell us about the Incident}

_{Answer the questions below or attach a copy of a supplementary} ^{document that answers them.}

6. Time employee began work: __________ _{am pm}

7

_{Check if time cannot}

_{be determined}

. Time of event: __________ _{am pm OR }

Event occurred: _before _during _after workshift

8. 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.”

9. 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.”

10. 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.”

11. 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.

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Case with Days Away from Work

Tell us about a 2004 occupational injury or illness only if it resulted in days away from work. To find out which case(s) you should report, read the instructions at the beginning of Part 2: Reporting Cases with Days Away from Work.

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)      	Job title (column C)      	Date of injury or onset of illness (column D)    /    /04 month day year	Number of days away from work (column K)      	Number of days of job transfer or restriction (column L)      

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 (11) 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 sex:

_ Male

_ Female

^{Tell us about the Incident}

_{Answer the questions below or attach a copy of a supplementary} ^{document that answers them.}

6. Time employee began work: __________ _{am pm}

7

_{Check if time cannot}

_{be determined}

. Time of event: __________ _{am pm OR }

Event occurred: _before _during _after workshift

8. 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.”

9. 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.”

10. 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.”

11. 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.

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Case with Days Away from Work

Tell us about a 2004 occupational injury or illness only if it resulted in days away from work. To find out which case(s) you should report, read the instructions at the beginning of Part 2: Reporting Cases with Days Away from Work.

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)      	Job title (column C)      	Date of injury or onset of illness (column D)    /    /04 month day year	Number of days away from work (column K)      	Number of days of job transfer or restriction (column L)      

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 (11) 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 sex:

_ Male

_ Female

^{Tell us about the Incident}

_{Answer the questions below or attach a copy of a supplementary} ^{document that answers them.}

6. Time employee began work: __________ _{am pm}

7

_{Check if time cannot}

_{be determined}

. Time of event: __________ _{am pm OR }

Event occurred: _before _during _after workshift

8. 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.”

9. 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.”

10. 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.”

11. 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.

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OCC

Case with Days Away from Work

Tell us about a 2004 occupational injury or illness only if it resulted in days away from work. To find out which case(s) you should report, read the instructions at the beginning of Part 2: Reporting Cases with Days Away from Work.

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)      	Job title (column C)      	Date of injury or onset of illness (column D)    /    /04 month day year	Number of days away from work (column K)      	Number of days of job transfer or restriction (column L)      

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 (11) 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 sex:

_ Male

_ Female

^{Tell us about the Incident}

_{Answer the questions below or attach a copy of a supplementary} ^{document that answers them.}

6. Time employee began work: __________ _{am pm}

7

_{Check if time cannot}

_{be determined}

. Time of event: __________ _{am pm OR }

Event occurred: _before _during _after workshift

8. 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.”

9. 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.”

10. 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.”

11. 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

P

S

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OCC

Case with Days Away from Work

Tell us about a 2004 occupational injury or illness only if it resulted in days away from work. To find out which case(s) you should report, read the instructions at the beginning of Part 2: Reporting Cases with Days Away from Work.

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)      	Job title (column C)      	Date of injury or onset of illness (column D)    /    /04 month day year	Number of days away from work (column K)      	Number of days of job transfer or restriction (column L)      

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 (11) 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 sex:

_ Male

_ Female

^{Tell us about the Incident}

_{Answer the questions below or attach a copy of a supplementary} ^{document that answers them.}

6. Time employee began work: __________ _{am pm}

7

_{Check if time cannot}

_{be determined}

. Time of event: __________ _{am pm OR }

Event occurred: _before _during _after workshift

8. 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.”

9. 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.”

10. 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.”

11. 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

P

S

E

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OCC

Case with Days Away from Work

Tell us about a 2004 occupational injury or illness only if it resulted in days away from work. To find out which case(s) you should report, read the instructions at the beginning of Part 2: Reporting Cases with Days Away from Work.

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)      	Job title (column C)      	Date of injury or onset of illness (column D)    /    /04 month day year	Number of days away from work (column K)      	Number of days of job transfer or restriction (column L)      

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 (11) 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 sex:

_ Male

_ Female

^{Tell us about the Incident}

_{Answer the questions below or attach a copy of a supplementary} ^{document that answers them.}

6. Time employee began work: __________ _{am pm}

7

_{Check if time cannot}

_{be determined}

. Time of event: __________ _{am pm OR }

Event occurred: _before _during _after workshift

8. 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.”

9. 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.”

10. 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.”

11. 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

P

S

E

SS

OCC

Contact Information

Fill in the name, title, and phone number of the person we should call with questions about the survey.

_________________________________________		(________) _______-________ ___________	(________) ______-__________
Printed name		Telephone number Ext.	Fax number

_________________________________________		/ / 
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).

If You Need Help . . .

If you have any questions or if you need help completing this survey, call the phone number that is listed below for your State. The phone number 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) 242-3460

(334) 240-3417 fax

Alaska

(907) 465-4539

(907) 465-2101 fax

Arizona

(602) 542-3739

(602) 542-6360 fax

Arkansas

(501) 682-4542

(501) 682-4754 fax

California

(415) 703-3020

(415) 703-3029 fax

Colorado

(816) 426-2483

Connecticut

(860) 566-4380

(860) 566-1731 fax

Delaware

(302) 761-8221, 8223

(302) 761-6605 fax

District of Columbia

(202) 442-5920, 5930

(202) 442-4833 fax

Florida

(850) 413-1611

(800) 219-8953

(850) 922-0024 fax

Georgia

(404) 679-0687 ext. 114, 117

(404) 679-5818 fax

Guam

(671) 647-6521

(671) 647-6516 fax

Hawaii

(808) 586-9001

(808) 586-9022 fax

Idaho

(415) 975-4473

(415) 975-4472 fax

Illinois

(217) 524-2098

(217) 557-5152 fax

Indiana

(317) 232-2668

(317) 233-3790 fax

Iowa

(515) 281-3661

(515) 242-5076 fax

Kansas

(785) 296-5642

(785) 291-3612 fax

Kentucky

(502) 564-3070

ext. 277

(502) 564-1682 fax

Louisiana

(225) 342-3126

(225) 342-3269 fax

Maine

(207) 624-6453

(207) 624-6450 fax

Maryland

(410) 767-2373

(410) 333-7909 fax

Massachusetts

(617) 727-3593

(617) 727-5726 fax

Michigan

(517) 322-1848

(517) 322-5117 fax

Minnesota

(651) 284-5428

(888) 589-6322

(651) 284-5726 fax

Mississippi

(404) 562-2518

(404) 562-2542 fax

Missouri

(573) 751-2719, 2663, 3802

(573) 751-2319 fax

Montana

(800) 541-3904

Nebraska

(402) 471-3547

(800) 599-5155

(402) 742-2352 fax

Nevada

(775) 684-7081

(775) 687-3826 fax

New Hampshire

(617) 565-2302

(617) 565-3847 fax

New Jersey

(609) 633-0755

(609) 633-0618 fax

New Mexico

(505) 827-4230

(505) 476-8566 fax

New York

(212) 352-6688, 6691

(212) 352-6711 fax

North Carolina

(919) 733-2758

(919) 733-2186 fax

North Dakota

(312) 353-7253

(312) 353-7230 fax

Ohio

(312) 353-7253

(312) 353-7230 fax

Oklahoma

(405) 528-1500 ext. 257

(405) 528-3412 fax

Oregon

(503) 947-7030

(503) 378-3134 fax

Pennsylvania

(215) 861-5637, 5638

(215) 861-5736 fax

Puerto Rico

(787) 754-2467

(787) 765-4687 fax

Rhode Island

(401) 462-8820

(401) 462-8766 fax

South Carolina

(803) 734-9653, 4298

(803) 734-9772 fax

South Dakota

(312) 353-7253

(312) 353-7230 fax

Tennessee

(800) 778-3966

(615) 741-1748

(615) 253-5501 fax

Texas

(866) 237-6405 toll free

(512) 804-4652 fax

Utah

(801) 530-6926, 6823

(801) 536-7906 fax

Vermont

(802) 828-5076

(802) 828-2195 fax

Virgin Islands

(340) 776-3700 ext. 2135

(340) 777-4803 fax

Virginia

(804) 786-8011

(804) 786-8418 fax

Washington

(360) 902-5640

(360) 902-5529 fax

West Virginia

(304) 558-3322

(800) 652-9033

(304) 558-0301 fax

Wisconsin

(800) 884-1273

(608) 266-3058 fax

Wyoming

(866) 518-6680

(307) 473-3863 fax