BLS 9300 SOII Adobe Form

U.S. Department of Labor
Bureau of Labor Statistics

Survey of Occupational Injuries and Illnesses, 2010
YOUR RESPONSE HELPS KEEP AMERICA’S WORKPLACES SAFE.
Refer to the 2010 SOII survey instructions you received in the mail.

Enter your 12-digit Establishment ID and e-mail in the fields below.
Your Establishment ID can be found on the front right side of the survey instructions you received and will be similar to this:
*Establishment ID:

- -

Establishment ID:
01-123456789-1

*E-Mail:
*Required to use this form.

Enter your company name and mailing address in
the fields below.

PRIMARY COMPANY NAME
{SECONDARY COMPANY NAME}
REPORT FOR:
ADDRESS LINE 1
ADDRESS LINE 2
CITY, STATE ZIP-PLUS+4
|||||||||||||||||||||||||||||||||||||||||||||||||||||||

Company Name:

Street Address 1:
Street Address 2:

City:
State:
ZIP:

-

Enter your contact information below.
Name:
Title:
Phone:

-

-

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

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OMB No. 1220-0045
BLS-9300

N06

Section 1: Establishment Information
Instructions: Using your completed Calendar Year 2010 Summary of Work-Related Injuries and Illnesses (OSHA Form
300A), copy the establishment information into the boxes. If these numbers are not available on your OSHA Form 300A, or if
your establishment does not keep records needed to answer (1) and (2) below, provide estimates by following the instructions on
the next page.

1. Enter the annual average number of employees for 2010.
2. Enter the total hours worked by all employees for 2010.
3. Check any conditions that might have affected your answers to questions 1 and 2 above during 2010:
Strike or lockout

Shorter work schedules or fewer pay periods than usual

Shutdown or layoff

Longer work schedules or more pay periods than usual

Seasonal work

Other reason:
Nothing unusual happened to affect our employment or hours
figures

Natural disaster or adverse weather conditions

4. Did you have ANY work-related injuries or illnesses during 2010?
Yes. Go to Section 2: Summary of Work-Related Injuries and Illnesses, 2010, directly below.
No. Go to Section 4: Submit Your Data to the Bureau of Labor Statistics (BLS).

Section 2: Summary of Work-Related Injuries and Illnesses, 2010
Instructions:
1. Refer to the OSHA Forms for Recording Work-Related Injuries and Illnesses for the location referenced on the survey
instructions under “Report For.”
2. If more than one establishment is noted on the survey instruction sheet you received in the mail, please provide
information for all of the establishments specified.
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).
Number of Cases
Total number of deaths

Total number of cases
with days away from
work

Total number of cases
with job transfer or
restriction

(G)

(H)

(I)

Total number of other
recordable cases

(J)

Number of Days
Total number of days of job
transfer or restriction

Total number of days
away from work

(K)

(L)

Injury and Illness Types
Total number of …
(M)
(1) Injuries

(4) Poisonings

(2) Skin disorders
(3) Respiratory conditions

(5) Hearing loss
(6) All other illnesses

If you had any work-related deaths in 2010, please tell us in the Comments in Section 4 of this survey where you
assigned/classified each death within the list of items (M1) through (M6) provided under Injury/Illness Types above (e.g.,
"fatal case was due to injury resulting from fall" or "death resulted from respiratory conditions").
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Steps to estimate annual average number of employees for 2010:
Step 1:
To calculate the annual average number of employees your
establishment paid during 2010, you must calculate the total
number of employees your establishment paid for all
periods. Add the number of employees your establishment
paid in every pay period during calendar year 2010. Count
all employees that you paid at any time during the year and
include full-time, part-time, temporary, seasonal, salaried,
and hourly workers. Note that pay periods could be
monthly, weekly, bi-weekly, etc.

Example:
Acme Construction paid its employees in 12 pay periods during
2010:
Pay Period

Number of Employees Paid
Per Pay Period
30
0
35
37
37
40
43
42
37
35
30
+26
392 (total number of employees paid over all
pay periods)

1
2
3
4
5
6
7
8
9
10
11
12

Step 2:
Divide the total number of employees (from step 1) by the
number of pay periods your establishment had in 2010. Be
sure to count any pay periods when you had no (zero)
employees.

Example:
Acme Construction had 12 pay periods and paid a total of 392
employees during these pay periods.

Step 3:
Round the answer you computed in step 2 to the next highest
whole number. Write that number in the box for Section 1,
question 2 on the previous page.

Example:
Acme would round 32.67 to 33.

392 divided by 12 = 32.67

Steps to estimate total hours worked by all employees for 2010:
Step 1:
Determine the number of full-time employees at your
establishment.

Example:
Of Acme's 33 employees in 2010, 28 were full-time.

Step 2:
Determine the number of hours generally worked by a fulltime employee for a year. Multiply the number of full-time
employees you calculated in step 1 by this number. This total
number of full-time hours worked should exclude vacation, sick
leave, holidays, and any other non-work time.

Step 3:
Determine the number of hours of overtime worked by your
full-time employees.
Determine the number of regular hours worked by your nonfull-time employees. (Non-full-time employees include parttime, seasonal, and temporary employees.)
Add these numbers to the number you calculated in step 2
above. This is the estimated number of hours worked by all
of your employees - full-time and non-full-time - during
2010. Write this number in Section 1, question 3 on the
previous page.
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Example:
Each of Acme's 28 full-time employees worked an average of
2,000 hours per year after excluding vacation, sick leave,
holidays, and other non-work time. This works out to 40 hours
per week for 50 weeks of the year.
28 full-time employees
X 2,000 hours per year
56,000 total full-time hours

Example:
Acme's 28 full-time employees worked a total of 2,800 hours of
overtime during 2010 and 56,000 regular hours. Acme's 5 parttime employees worked a total of 2,715 hours during 2010.
56,000
2,800
+ 2,715
61,515

full-time hours from step 2
over time hours
part-time hours
total hours worked

Section 3: Reporting Cases with Days Away from Work
Instructions:
Please refer to your records of days away from work cases to complete this section. If you maintain these records on the OSHA
Form 300, Log of Work-Related Injuries and Illnesses, these cases will be indicated by checks in column H (see sample below).
If you had cases with days away from work in Column H, please complete Section 3 (starting on the next page). You should
only report cases with days away from work.
If you had NO cases with days away from work in Column H, you are finished with the survey. Proceed to section 4 to submit
your data to BLS.

We have designed this survey so that you should not have to report more than approximately 15 cases. If you have significantly
more than 15 cases, please contact the state agency at the phone number listed on the front of the survey instructions you received
in the mail.
Step 1: Fill out one “Case with Days Away from Work” form for each work-related injury or illness resulting in days away
from work. The requested information can be found on documents such as:
The Injury and Illness Incident Report (OSHA Form 301);
A workers' compensation report;
An accident report; or
An insurance form.
Step 2: If more than one establishment is noted on the survey instructions under “Report For,” be sure to look at all of your
OSHA Form 300's to find which cases to report.
Step 3: If you had an injury or illness that resulted in death, please include a comment in the comment field in Section 4.
Step 4: When you are finished, proceed to Section 4 to submit your data to BLS.

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Case with Days Away from Work
Tell us about a 2010 work-related 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.
Date of injury
or
onset of illness
(column D)

Job title
(column C)

Employee’s name
(column B)

Number of days
away from work
(column K)

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

Tell us about the Incident

Tell us about the Employee
1. Check the category which best describes the employee's regular type
of job or work: (optional)
Office, professional, business or
management staff

Healthcare
Delivery or driving

Sales

Food service

Product assembly, product
manufacture
Repair, installation or service of
machines, equipment
Construction
Other

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

Native Hawaiian or Other
Pacific Islander

Asian

White

Black or African American

Not available

Hispanic or Latino

6. Time employee began work:

:

7. Time of event:

AM PM

Event occurred:

:
before

during

AM

PM

Check if time
cannot be
determined
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.”

3. Employee's age:
OR
Date of birth:
4. Employee's date hired:

OR check length of service at establishment when incident occurred:

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.”

Less than 3 months
From 3 to 11 months
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.

From 1 to 5 years
More than 5 years
5. Employee's gender:
Male

Female

Add New Case
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Remove Case

Section 4: Submit Your Data to BLS
1.

Comment
Provide any additional information you have on the data you are submitting in the space provided. If you had an
injury or illness that resulted in death, please tell us what injury/illness type you classified it as in Section 2.

2.

Save
Save a copy of this form for your records.

Save

3.

Print
Print a copy of this form for your records.

Print

4.

Submit
Click the Submit button to send your data to BLS.
You will receive a confirmation via e-mail within 24 hours of your data being received. If you have JavaScript enabled
in your browser, you may also receive a confirmation message within the next 5 minutes when we receive your data.

Submit

5.

Keep the confirmation
Keep a copy of the confirmation for your records.
If you do not receive an e-mail confirmation, contact your State at the phone number listed on the front of your survey
instructions for assistance in submitting your data.

Thank you for your response and for helping keep America’s workplaces safe.

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