OMB No. 1220-0045

 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 Consent can be withdrawn at anytime, but those data published during the period of consent cannot be retracted.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) 

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.  

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.