Informed Consent Notification Letter

Survey of Occupational Injuries and Illnesses Informed Consent

_____________ (State), in cooperation with the Bureau of Labor Statistics (BLS),
would like to publish statistical tabulations in ____________________ (industry name)
_______ (Industry code, TEI). In preparing the results of the survey, however, we found
that your company is a major reporter for your industry in (State) _______. Thus,
publishing 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 Consent can be withdrawn at anytime, but those data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 in
the workplace. If you have any questions, please call _______________________ of our
____ Office at ________________ (State phone number)
Sincerely,

(Name and Title)

On behalf of ___________________________________ (company,
establishment name), I hereby authorize ________________ (State) to publish statistical
tabulations for the Survey of Occupational Injuries and Illnesses in the above referenced
industry. Authorization is granted (please check one): ( ) on a continuous basis; ( )
for _____ Survey year 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) ____________________ (Date)
____________________________________ (Printed Name)
____________________________________ (Title)