BLS 9300 N06 SOII Collection Instrument

U.S. Department of Labor
Bureau of Labor Statistics

Survey of Occupational Injuries
and Illnesses, 2011
YOUR RESPONSE IS REQUIRED BY LAW IN 30 DAYS.

Please correct your company address as needed.

For your convenience, you can submit your survey response
on our website at https://idcf.bls.gov.

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
BLS-9300 N06

Steps to Complete this Survey
This survey requires employers to provide information about work-related injuries and illnesses based upon the
information you have maintained for Calendar Year 2011 on your Occupational Safety and Health Administration
(OSHA) Forms for Recording Work-Related Injuries and Illnesses. Copies of these forms were mailed to you in late
2010. Under Public Law 91-596, all establishments that receive this mandatory survey must complete and return it
within 30 days, even if they had no work-related injuries and illnesses during 2011. The instructions below outline the
steps to complete the survey regardless of whether your establishment did or did not have injuries or illnesses in 2011.
Step 1:

Complete this survey only for the establishment(s) noted on the front cover under “Report for this Location.” If
you are unsure, please call the number(s) listed on the front of this form in the “For Help Call:” section.

Step 2:

Check “Your Company Address” printed on the front cover. Make any necessary corrections directly on the
front cover.

Step 3:

Refer to your establishment’s OSHA Forms for Recording Work-Related Injuries and Illnesses. Copies of these
forms were mailed to you in late 2010. Form 300A from that mailing is shown immediately below.
OSHA’s Form 300A

Year 20__ __

(Rev. 01/2004)

Summary of Work-Related Injuries and Illnesses

U.S. Department of Labor
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176

All establishments covered by Part 1904 must complete this Summary page, even if no work-related injuries or illnesses occurred during the year. Remember to review the Log
to verify that the entries are complete and accurate before completing this summary .
Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you’ve added the entries from every page of the Log. If you
had no cases, write “0.”
Employees, former employees, and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access to the OSHA Form 301 or
its equivalent. See 29 CFR Part 1904.35, in OSHA’s recordkeeping rule, for further details on the access provisions for these forms.

Number of Cases
Total number of
deaths

Copy this
information to
Section 2 of
this survey.

Total number of
cases with days
away from work

Total number of
cases with job
transfer or restriction

Total number of
other recordable
cases

_____________

_____________

____________

___________

(G)

(H)

(I)

(J)

Establishment information
Your establishment name______________________________________
Street

____________________________________________________

City

_______________________

State ____________ Zip

________

Industry description ( (e.g., Manufacture of motor truck trailers)

Standard Industrial Classification (SIC), if known (e.g., SIC 3715)
____ ____ ____ ____

Number of Days

OR

Total number of days away
from work

Total number of days of job
transfer or restriction

_____________

______________

(K)

(L)

North American Industrial Classification (NAICS, if known (e.g., 336212))
____ ____ ____ ____ ____ ____
Employment information (If you don’t have these figures, see the
Worksheet on the back of this page to estimate.)

Injury and Illness Types
Total number of …

Annual average number of employees

_____________

Total hours worked by all employees last year

_____________

(M)
(1) Injuries

______

(4) Poisonings
(5) Hearing loss

(2) Skin disorders
(3) Respiratory conditions

______
______

(6) All other illnesses

Sign here

______
______
______

Knowingly falsifying this document may result in a fine.
I certify that I have examined this document and that to the best of my
knowledge the entries are true, accurate, and complete.

Post this Summary page from February 1 to April 30 of the year following the year covered by the form.
Public reporting burden for this collection of information is estimated to average 50 minutes per response, including time to review the instructions, search and gather the data needed, and
complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any
comments about the estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Avenue, NW, Washington,
DC 20210. Do not send the completed forms to this office.

Company executive

Title

(
)
Phone

/ /
Date

DATA COLLECTION AGENCY
SURVEY STAFF
123 MAIN STREET
MY CITY, US 12345-0000

Address for Return Envelope:

DATA COLLECTION AGENCY
SURVEY STAFF
123 MAIN STREET
MY CITY, US 12345-0000 \

Example
Copy your
account
number from
the label to
Section 1.

Your Establishment ID:
77-123456789-3

Report for this Location:
SAME AS YOUR COMPANY ADDRESS
For Help Call:

(555) 111-2222

Your Company Address:

Account Number:
302123456789

YOUR COMPANY NAME
987 YOUR STREET
YOUR CITY, US 98765-0000

Temporary Password:
9876Nsu
77-123456789-1
2007-1 NAICS 238000






Copy this
information
to Section 1
of this
survey.

NAICS code
location.

12 P 60 00

If you had no work-related injuries or illnesses in 2011, answer all questions in Sections 1 and 4 of the survey.
If you had at least one work-related injury or illness in 2011, answer all questions in Sections 1, 2 and 4 of the
survey.
Report cases with Days Away From Work (with or without days of job transfer or restriction) in Section 3.
Report cases with Job Transfer or Restriction (without days away from work) in Section 3 if your NAICS
code begins with these numbers: 238, 311, 444, 481, 493, or 623 (see mailing label example for NAICS code
location).

Step 4:

In case we have questions, write the name of the person who completed this survey in Section 4: Contact
Information, on the last page of this survey.

Step 5:

Return this survey and any attachments in the enclosed envelope within 30 days of the date your establishment
received it.
2

Section 1: Establishment Information
Instructions: Using your completed Calendar Year 2011 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 (2) and (3) below, you can estimate using the steps that follow
on the next page.
1. Enter your account number from the front cover.
2. Enter the annual average number of employees for 2011.
3. Enter the total hours worked by all employees for 2011.
4. Check any conditions that might have affected your answers to questions 2 and 3 above during 2011:
 Strike or lockout
 Shutdown or layoff
 Seasonal work
 Natural disaster or adverse weather
conditions
5.

 Shorter work schedules or fewer pay periods than usual
 Longer work schedules or more pay periods than usual
 Other reason: _________________________________
 Nothing unusual happened to affect our employment or hours figures

Did you have ANY work-related injuries or illnesses during 2011?
 Yes. Go to Section 2: Summary of Work-Related Injuries and Illnesses, 2011, directly below.
 No. Go to Section 4: Contact Information, on the back cover.

Section 2: Summary of Work-Related Injuries and Illnesses, 2011
Instructions:
1. Refer to the OSHA Forms for Recording Work-Related Injuries and Illnesses for the location referenced on the front
cover of the survey under “Report for this Location.” If you prefer, you may enclose a photocopy of your
Summary of Work-Related Injuries and Illnesses (OSHA Form 300A).
2. If more than one establishment is noted on the front cover of this survey, be sure to include the OSHA Form 300A
for all of the specified establishments.
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

____________________
(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

________
________
________

If you had any work-related deaths in 2011, please tell us on the line below where you assigned/classified each death
within the list of items (M1) through (M6) provided under Injury and Illness Types above (e.g., “fatal case was due
to injury resulting from fall” or “death resulted from respiratory conditions”)_________________________________
________________________________________________________________________________________________
3

Steps to estimate annual average number of employees for 2011:
Step 1:
To calculate the annual average number of employees your
establishment paid during 2011, 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 2011. 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 2011:

Step 2:
Divide the total number of employees (from Step 1) by the number of
pay periods your establishment had in 2011. 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.

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

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)

392 divided by 12 = 32.67

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.

Steps to estimate total hours worked by all employees for 2011:
Step 1:
Determine the number of full-time employees at your establishment.

Example:
Of Acme’s 33 employees in 2011, 28 were full-time.

Step 2:
Determine the number of hours generally worked by a full-time
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.

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

Step 3:
Determine the number of hours of overtime worked by your full-time
employees.
Determine the number of regular hours worked by your non-full-time
employees. (Non-full-time employees include part-time, 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 2011. Write this number in Section
1, Question 3 on the previous page.
4

Example:
Acme’s 28 full-time employees worked a total of 2,800
hours of overtime during 2011 and 56,000 regular hours.
Acme’s 5 part-time employees worked a total of 2,715
hours during 2011.
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
Instructions:
1. If you had NO cases with days away from work (Column H) and NO cases with days of job transfer or restriction
(Column I), please proceed to Section 4: Contact Information.
2. If you had cases with days away from work (Column H) and/or cases with days of job transfer or restriction only
(Column I), please complete Section 3. You should report all cases with days away from work (with or without job
transfer or restriction). If your NAICS code begins with: 238, 311, 444, 481, 493, or 623, you should also report all
cases with days of job transfer or restriction (without days away from work). Your NAICS code is located on the
mailing label on the front of this booklet. To identify the individual cases to report, follow these steps:
Step 1:

Go to your completed OSHA Form 300.
Note each case that has a check in Column (H) and/or Column (I).
These are the only cases you should report.
See the illustration in Step 3 below.

Step 2:

Fill out one Injury and Illness Case Form for each case that you identified in Step 1. You can find most of
the information on a supplementary document such as the Injury and Illness Incident Report (OSHA Form
301), a workers’ compensation report, an accident report, or an insurance form.

Step 3:

If more than one establishment is noted on the front cover under “Report for this Location,” be sure to
look at all your OSHA Form 300’s to find which cases to report.

Section 3 asks about injuries
or illnesses with a check in
Column H, Days Away from
Work and/or Column I, Job
Transfer or Restriction, of
your Log.

Step 4:

We have designed this survey to ensure that you do not have to report more than approximately 15 cases. If
you have significantly more than 15 cases, please go to Section 5: If You Need Help . . . at the back of this
booklet and call the phone number(s) listed for your State for assistance. If you need additional Injury and
Illness Case Forms, you may either photocopy a blank form or go to Section 5: If You Need Help . . . at the
back of this booklet and call the phone number(s) listed for your State.

Step 5:

When you are finished, proceed to Section 4: Contact Information on the back cover of this booklet and
provide information for the person who completed this survey.
5

Injury and Illness Case Form
Tell us about a 2011 work-related injury or illness only if it resulted in days away from work or job transfer/restriction. To find out
which case(s) you should report, read the instructions at the beginning of Section 3: Reporting Cases.
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)

/
month

Number of days
away from work
(Column K)

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

/11
day

year

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. Was employee treated in an emergency room? yes

no
7. Was employee hospitalized overnight as an in-patient? yes no
8. Time employee began work: __________ am pm
9. Time of event: __________ am pm OR  Check if time cannot
be determined
Event occurred: (optional) before during after work shift

Healthcare
Delivery or driving
Food service
Cleaning, maintenance
of building, grounds
Material handling (e.g.,stocking,
loading/unloading, moving, etc.)

Farming

10. 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.”

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









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

11. 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 (13) or attach a copy of a
supplementary document that answers them.
3. Employee’s age: ______ OR date of birth: ______/______/______
month

day

12. 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.”

year

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

day

year

OR check length of service at establishment when incident
occurred:






5. Employee’s gender:
 Male
 Female
N

13. 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.

Less than 3 months
From 3 to 11 months
From 1 to 5 years
More than 5 years

P

S

E

SS

6

OCC

Injury and Illness Case Form
Tell us about a 2011 work-related injury or illness only if it resulted in days away from work or job transfer/restriction. To find out
which case(s) you should report, read the instructions at the beginning of Section 3: Reporting Cases.
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)

/
month

Number of days
away from work
(Column K)

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

/11
day

year

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:____________________








8. Was employee treated in an emergency room? yes

no
9. Was employee hospitalized overnight as an in-patient? yes no
8. Time employee began work: __________ am pm
9. Time of event: __________ am pm OR  Check if time cannot
be determined
Event occurred: (optional) before during after work shift

Healthcare
Delivery or driving
Food service
Cleaning, maintenance
of building, grounds
Material handling (e.g.,stocking,
loading/unloading, moving, etc.)

Farming

10. 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.”

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









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

11. 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 (13) or attach a copy of a
supplementary document that answers them.
12. 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.”

3. Employee’s age: ______ OR date of birth: ______/______/______
month

day

year

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

day

year

OR check length of service at establishment when incident
occurred:






5. Employee’s gender:
 Male
 Female
N

13. 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.

Less than 3 months
From 3 to 11 months
From 1 to 5 years
More than 5 years

P

S

E

SS

7

OCC

Section 4: Contact Information
Fill in the name, title, and phone number of the person who completed this survey in case we have questions.
Printed name

(
)
Telephone number

Title

/
Today’s date

Ext.

(
)
Fax number

-

/

Use the return envelope to send us the entire package -- everything that we sent you -- within 30 days of the date
your establishment received it. If the return envelope is missing, send the entire package to the return address on
the front cover (look for Address for Return Envelope).

Section 5: If You Need Help . . .
If you have any questions or if you need help completing this survey, call the phone number(s) that is listed below for
your State. The phone number(s) may be for an office outside your State, but they will be able to help you. If you
prefer to write, send your letter to the return address on the front of this package.
Alabama
(334) 242-3461, 3463
(334) 240-3417 fax
Alaska
(907) 465-4539
(907) 465-4506 fax
Arizona
(602) 542-3739
(602) 542-6360 fax
Arkansas
(501) 682-4509
(501) 682-4754 fax
California
(415) 703-3020
(415) 703-3029 fax
Colorado
(816) 285-7146
(816) 285-7031
(972) 850-4810 fax
Connecticut
(860) 263-6941
(860) 263-6950 fax
Delaware
(302) 761-8221
(302) 762-3590 fax
District of Columbia
(202) 442-9010, 5926, 5930
(202) 442-4833 fax
Florida
(215) 861-5638, 5628
(215) 861-5736 fax
Georgia
(404) 679-1746, 1747, 1656
(404) 679-0520 fax
Guam
(671) 475-7056
(671) 475-7063 fax
Hawaii
(808) 586-9001
(808) 586-9022 fax
Idaho
(415) 625-2275, 2271, 2267
(415) 625-2356 fax

Illinois
(217) 524-2098
(217) 558-4122 fax
Indiana
(317) 232-2668
(317) 233-3790 fax
Iowa
(515) 281-3618
(515) 242-5076 fax
Kansas
(785) 296-1640
(785) 296-2151 fax
Kentucky
(502) 564-4259, 4136, 4135
(502) 564-0091 fax
Louisiana
(225) 342-3126
(225) 342-3269 fax
Maine
(207) 623-7903, 7904
(207) 623-7937 fax
Maryland
(410) 527-4460, 4461, 4462
(410) 527-4497 fax
Massachusetts
(617) 626-6945
(617) 626-6944 fax
Michigan
(517) 322-1848
(517) 322-5117 fax
Minnesota
(888) 589-6322
(651) 284-5726 fax
Mississippi
(404) 893-1934, 8344
(404) 893-8343 fax
Missouri
(573) 751-3802, 2663
(573) 751-2319 fax
Montana
(800) 541-3904
(406) 444-2638 fax

Nebraska
(402) 471-3547, 1545
(800) 599-5155
(402) 742-2352 fax
Nevada
(866) 931-1215
(702) 486-9187
(702) 486-9175 fax
New Hampshire
(617) 565-2302
(617) 565-3847 fax
New Jersey
(609) 292-8999
(609) 633-0618 fax
New Mexico
(505) 476-8740, 8708, 8704
(505) 476-8735 fax
New York
(888) 425-1323
(888) 807-0410 fax
North Carolina
(919) 733-2758
(919) 733-2186 fax
North Dakota
(312) 353-7253
(312) 353-7230 fax
Ohio
(312) 353-7253
(312) 353-7230 fax
Oklahoma
(405) 521-6857
(405) 521-6021 fax
Oregon
(503) 947-7030
(503) 947-7085 fax
Pennsylvania
(800) 238-9412
(717) 705-4318 fax
Puerto Rico
(787) 754-5300, ext. 3032,
3036, 3051, 3056, 3057
(787) 754-5360 fax

8

Rhode Island
(617) 565-2302
(617) 565-3847 fax
South Carolina
(803) 896-7659, 7683
(803) 896-4676 fax
South Dakota
(312) 353-7253
(312) 353-7230 fax
Tennessee
(615) 741-1748
(800) 778-3966
(615) 253-5501 fax
Texas
(866) 237-6405
(512) 804-4652 fax
Utah
(801) 530-6926, 6823
(801) 536-7906 fax
Vermont
(802) 828-5985
(802) 828-2195 fax
Virgin Islands
(340) 776-3700 ext. 2135, 2667
(340) 777-4803 fax
Virginia
(804) 786-1035, 1995, 7616
(804) 786-8418 fax
Washington
(360) 902-5640
(360) 902-4249 fax
West Virginia
(800) 652-9033
(304) 558-2658
(304) 558-0301 fax
Wisconsin
(800) 884-1273
(608)-221-6294
(608) 221-6297 fax
Wyoming
(866) 518-6680
(307) 473-3838
(307) 473-3863 fax