BLS 9300 FAX SOII Fax form

U.S. Department of Labor, Bureau of Labor Statistics

Survey of Occupational Injuries
and Illnesses, 2010
Alabama Fax Response Form
Send to (334) 240-3417
Employers selected for the BLS Survey of Occupational Injuries and Illnesses are required by Federal Law to respond.
If you have questions please contact us at the phone number listed on the front of your survey instructions.
Section 1: Establishment Information

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Establishment ID Number (from front of survey instructions)
Today’s Date

Company Name and Report For (from front of survey instructions)
Contact Name and Title (please print)

Telephone Number (ext)
(
)
-

(

)

Fax Number
-

1 Enter the annual average number of employees for 2010.
2. Enter the total hours worked by all employees for 2010.
3. Did you have ANY work-related injuries or illnesses during 2010?
 Yes.
Complete Section 2 below.
 No.
Please see instructions at the bottom of page 2.
Section 2: Summary of Work-Related Injuries and Illnesses
1. Refer to the OSHA Forms for Recording Work-Related Injuries and Illnesses for the location referenced on the front
of the survey instructions under Report For.
2. If you prefer, you may fax your Summary of Work-Related Injuries and Illnesses (OSHA Form 300A) with this form. If more
than one establishment is noted on the front of the survey instructions, be sure to fax the OSHA Form 300A for each of the
specified establishments.
3. If any total is zero on your OSHA Form 300A, write “0” in that 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

____________________
(G)

Total number of cases
with days away from
work

Total number of cases
with job transfer or
restriction

_________________
(H)

_________________
(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

________
________
________
OMB No. 1220-0045
BLS-9300 FAX

Case with Days Away from Work
If you reported cases resulting in days away from work in column H in section 2 on page 1, tell us about the 2010 work-related
injuries or illnesses. One Case with Days Away from Work form should be completed for each injury or illness listed in column H.
Most of this information about the employee and the incident can be found on OSHA Form 301.
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)

/
mm

Number of days
away from work
(column K)

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

/10
dd

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:____________________




6. Time employee began work: __________ am

Healthcare
Delivery or driving
Food service
Cleaning, maintenance
of building, grounds
Material handling (e.g.,stocking,

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.”

loading/unloading, moving, etc.)

Farming

2. Employee’s race or ethnic background: (optional-check one or more)









pm
if time cannot
 Check
be determined

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Not available

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: ______/______/______
mm

dd

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.”

yy

4. Employee’s date hired: ______/______/______
mm

dd

yy

OR check length of service at establishment when incident
occurred:






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

Thank you for your participation. Please fax your completed forms to (334) 240-3417.
For office use
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