Survey of Occupational Injuries and Ilnesses - State and Local

U .S. Department of Labor

Bureau of Labor Statistics

Instructions for the Survey of Occupational

Injuries and Illnesses, 2009

YOUR RESPONSE IS REQUIRED BY LAW IN 30 DAYS

Establishment ID:

01-203479880-1

PRIMARY COMPANY NAME

{SECONDARY COMPANY NAME}

REPORT FOR: {RUD} OR BLANK

ADDRESS LINE 1

ADDRESS LINE 2

CITY, STATE ZIP-PLUS+4

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^{Options to Report Your Data}

Option 1: Report your data through the Internet Data Collection Facility (IDCF)

on the Bureau of Labor Statistics (BLS) website:

https://idcf.bls.gov

Option 2: Request an electronic fillable form of the survey and respond by e-mail.

[email protected]

^{To see how your data will be used, please go to www.bls.gov/iif}

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 Approval expires 09-30-2010 BLS-9300-IDCF

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 2009.

In December 2008, you were notified of your participation in the BLS 2009 Survey of Occupational Injuries and Illnesses (SOII) and asked to maintain records of workplace injuries and illnesses throughout 2009.

Forms to help you complete the survey

• OSHA’s Form 300 - Log of Work-Related Injuries and Illnesses; includes all injuries and illnesses for the year

• OSHA’s Form 300A - Summary of Work-Related Injuries and Illnesses; includes average employment and total hours worked

• OSHA’s Form 301 - Injury and Illness Incident Report; includes detailed injury and illness data

• State Worker’s Compensation Forms

Option 1: Use the Internet

Before reporting your data, you must register with the BLS even if you registered in previous years or for other surveys.

1. Go to https://idcf.bls.gov on your internet browser. The “s” in “https” is required. Click Cancel if a Client Authentication or Choose a Digital Certificate pop-up window appears.

2. Enter the 12-digit Account Number in the field labeled “Account Number” and the Temporary Password in the field labeled “Password”. Click I Accept.

3. Complete the “Enter New User Information” page and “Create a Permanent Password” page.

4. Click Continue on the “Confirmation and Security Option Notice” page.

5. Report your data and click Submit when you are finished. Print a copy of the completed survey for your records.

Option 2: Use a Fillable Form via E-Mail

You may obtain an electronic fillable form of the survey, which allows you to type your information directly into each data field.

1. Obtain an electronic fillable form of the survey (Adobe ® PDF fillable form) by calling the phone number or sending an e-mail to the address listed on the front of this form. Please include your establishment ID in the subject line of your e-mail request.

2. Save the form to your computer and open it using Adobe Reader® 8.0 or higher. If you do not have Adobe Reader 8.0 or higher, you can download it for free from www.Adobe.com.

3. Enter your Establishment ID and company name and address in the spaces provided, and injury and illness data. See the example below.

You will need your company address and Establishment ID if you report using the fillable form via e-mail.

4. Save the form on your computer when you have entered all of your injury and illness data. Print a copy of the completed form for your records.

5. Send the data to the BLS by clicking Submit Data to BLS. You will receive a confirmation on-screen when your data have been received by the BLS. If you do not receive this confirmation, contact your State at the number listed on the front of your form.

Need help?

• Go to http://www.bls.gov/respondents/iif/ to download forms and get answers to frequently asked questions.

• Click the Help link that appears on each online screen at https://idcf.bls.gov.

• Contact [email protected] for password or registration help.

• Go to http://www.bls.gov/idcf/instructions.htm for additional registration instructions.

• Contact us using the phone number listed on the front of this form for questions regarding the survey.