BLS-9300 FAX Survey of Occupational Injuries and Illnesses, 2007

Survey of Occupational Injuries
and Illnesses, 2007
U.S. Department of Labor, Bureau of Labor Statistics

FAX Response Form
Complete and FAX to us at (XXX) XXX-XXXX
If there were few or no work-related injuries and illnesses at this establishment in calendar year 2007, you can complete and
fax this form, along with forms for any cases with days away from work, in order to fulfill your obligation in responding to
this mandatory survey. If you respond via this FAX, do not mail in your survey form or reply by the Internet or e-mail.
1. Refer to your Reporting Site’s OSHA Forms for Recording Work-Related Injuries and Illnesses.
2. 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.
3. If any total is zero on your OSHA Form 300A, write “0” in that total’s 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).

COMPANY NAME and REPORTING SITE (as it appears on the cover of your survey booklet):
Establishment ID Number (appears directly under “Your Company Address:”)
99 -

- 2007

Contact Name and Title

Telephone Number (ext)
(

Date

)

-

FAX number
/

/

(

)

-

1 Enter the annual average number of employees for 2007.
2. Enter the total hours worked by all employees for 2007.
3. Did you have ANY occupational injuries or illnesses during 2007?
‰ Yes. Complete the Next Section directly below. ‰ No. You are done. Please FAX this (XXX) XXX-XXXX.
Number of Cases
Total number of deaths

____________________
(G)

Total number of cases
with days away from
work

Total number of cases
with job transfer or
restriction

_________________
(H)
NOTE:

_________________
(I)

Total number of other
recordable cases

_________________
(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
(2) Skin disorders
(3) Respiratory conditions

________
________
________

(4) Poisonings
(5) Hearing loss
(6) All other illnesses

If any cases
are recorded
in Column H,
please
complete a
Case with
Days Away
from Work
form for each
case and
include with
your FAX
return.

________
________
________
OMB No. 1220-0045
Approval expires xx-xx-xx
BLS-9300 FAX

Case with Days Away from Work
Tell us about a 2007 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 Section 3: 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)

Date of injury
or
onset of illness
(column D)

Job title
(column C)

/
month day

Number of days
away from work
(column K)

Number of days
of job transfer
or restriction
(column L)

/07
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,
loading/unloading, moving, etc.)

Farming

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

6. Time employee began work: __________ ‰am

‰pm
if time cannot
‰ Check
be determined

7. Time of event: __________ ‰am
Event occurred:

‰before

‰pm OR
‰during ‰after

work shift

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.”

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

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.”

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

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.

5. Employee’s gender:
‰ Male
‰ Female
N

P

S

E

SS

OCC