Form CFOI - 1 CFOI - 1 Census of Fatal Occupational Injuries

Bureau of Labor Statistics U.S. Department of Labor

Census of Fatal
Occupational Injuries Report

This report is authorized by Public Law 91-596. 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. 1220-0133 Approval Expires 2/28/2014
ID	Public Burden Statement: Your voluntary cooperation is needed to make the results of this study comprehensive, accurate, and timely. The Bureau estimates that it will take from 10 to 30 minutes to complete this form, with an average of 20 minutes, including time for gathering the information needed and completing the form. If you have any comments regarding this estimate or any other aspect of this data collection, including suggestions for reducing this burden, you may send them to the Bureau of Labor Statistics, CFOI Program, 2 Massachusetts Avenue, NE, Room 3180, Washington, DC 20212-0001. Do not send the completed form to this address. You do not have to complete this form if it does not display a currently valid OMB Control Number.
Return to: For assistance call:
Instructions: Some information about the incident is already provided on this form. Please review this information and do the following: Correct any inaccurate information. Add any missing information. If you cannot answer a question, please indicate that you do NOT have sufficient information to answer the question. Please contact us if you have any questions regarding this form.
SECTION I. DECEASED WORKER AND EMPLOYER NAME: _________________________________________________________________

1. Legal name: (Please print): _________________________________________________________
   (Last) (First) (Middle)

2. Social Security Number: ______________________

3. Employer at the time of the incident:

_____________________________________________________________________________

(Company name)

_____________________________________________________________________________

(Street address)

_____________________________________________________________________________

(City) (State) (Zip code)

(___________________) ___________________________________________________

(Area code) (Phone number)

BLS CFOI - 1

___ ____

ST ID

4. Date of birth: ________________________________________________________________

(Month) (Day) (Year)

5. Ethnicity and race: (Select one or more)

 American Indian or Alaska Native  Asian

 Black or African American  Hispanic or Latino

 Native Hawaiian or Other Pacific Islander  White

6. Sex:  Male  Female

7. In what state did the deceased reside? _____________________________________________

SECTION II. EMPLOYMENT INFORMATION

1. Which of the following BEST describes the deceased's employment status at the time of

the incident? (Check only ONE)

 Active duty, Armed Forces

 Self-employed, partner, owner of business, farm, or professional practice (Check only ONE:

 incorporated  unincorporated )

 Working for the family business, except owner (includes paid or unpaid work)

 Working for pay or other compensation (such as room and board) in other than the family business

 Working as a volunteer without pay or other compensation

 Other (Please specify:) _________________________________________________________

 Don't know

2. Occupation of deceased at the time of the incident: (Examples include: cashier, drywall installer,
   farm foreman) _______________________________________________________

3. How long did the deceased work in the position held at the time of the incident?

years months (if less than 1 year)

4. Which of the following best describes the type of employer the deceased was directly employed by? (Check only ONE)

 a private company or self-employed  a Federal government agency

 a local government agency  a foreign or international government agency

 a State government agency  other governmental body, such as a regional

or interstate commission

___ ____

ST ID

5. Describe the nature of the business or the main type of activity performed by the employer

at the establishment. (Examples include: manufacturer of storage batteries, grocery store,

computer programming services, etc.)

________________________________________________________________________________

6. On average, about how many persons work for the employer at the actual location or

worksite where the incident occurred? (Check only ONE)

 1-10  11-19  20-49  50-99  100 or more  don't know

SECTION III. INFORMATION ABOUT THE INCIDENT

1. Date of death: ___________________________________________________________________

(Month) (Day) (Year)

2. State in which death occurred: _____________________________________________________

3. Date the incident occurred: ________________________________________________________

(Month) (Day) (Year)

4. Where did this incident occur?

State: _______________________________________________________________________

County: _____________________________________________________________________

Type of location (Examples include: farm, highway, bank, etc.):
_____________________________________________________________________

5. Did the incident occur on the employer's premises?

• no

• y es If YES, where did the incident occur?

 in a work area  in a hallway, stairway, rest room, or cafeteria

 in the company parking lot  some other place (Please specify):

 on an outside walkway ____________________________________

 in a recreational area  don’t know

___ ____

ST ID

6. What was the deceased doing at the time of the incident? (Mark ALL that apply.)

 normal commute between home and usual work location

 job-related errand or travel other than commuting to or from work

 attending training provided or required by the employer

 routine or typical work activity (Please specify): ___________________________________

 other activity on the employer premises

• work-related activity (Please specify): ___________________________________________

• non-work-related activity (Please specify): _______________________________________

 non-work-related personal business

 don't know

7 . What time did the incident occur? Check only ONE:  AM  PM

8 . What time did the deceased's workday

begin on the day the incident occurred? Check only ONE:  AM  PM

9. The injury/illness resulted from: (Check the MOST accurate statement.)

 an incident, such as a fall, explosion, shooting, etc.

 an exposure to a chemical, substance, or environmental factor lasting a day or less

 an exposure to a chemical, substance, or environmental factor lasting more than a day

 heart attack/stroke

 natural causes other than heart attack or stroke

 other (Please specify): ____________________________________________________

10. Please provide more specific details to describe the injury/illness and the events which

resulted in the injury/illness:

a. Include information about how the injury/illness occurred.

b. Identify any equipment, objects, or substances involved in the incident and describe

how they were involved. (Please use additional pages if more space is needed.)

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

SECTION IV. RESPONDENT IDENTIFICATION

Please provide the following information:

1. Your name: _____________________________________________________________________

2. Your job title: ___________________________________________________________________

3. Your daytime phone number: (__________) _____________________________________

(Area code) (Phone number)

4. Date you completed this form: ____________________________________________________

(Month) (Day) (Year)