196B OSHA Work-Related Injury and Illness Data Collection

OSHA WOrk-relAted Injury And
IllneSS dAtA COlleCtIOn FOrm, 2011
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U.S. Department of Labor
Occupational Safety and Health Administration

OMB No. 1218-0209
Approval Expires 4/30/2013
OSHA Form 196B
(1/2012)

Public Law 91-596
requires you to
participate in the data
initiative collection.

Place Label Here

OSHA estimates that it
will take you, on average,
10 minutes to complete
the forms in this data
collection, including the
time you’ll spend reviewing
the instructions, searching
and gathering the data
needed, and completing and
reviewing 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
regarding these estimates or
any other aspects of this data
collection, send them to:

U.S. Department of Labor
Occupational Safety and
Health Administration
Directorate of Evaluation
and Analysis
Office of Statistical Analysis
Room N-3644
200 Constitution Ave. N.W.
Please make any necessary corrections to your establishment site address, SIC, and NAICS. Washington, D.C. 20210

OSHA Log
Data Collection

To submit your data electronically, access
our electronic survey at
http://www.osha.gov/form196/collection.htm

DO NOT SEND THE
COMPLETED FORM
TO THIS ADDRESS.
Send the completed form
to the Return Address
indicated on the mailing
label.

Dear Employer:

The U.S. Department of Labor, Occupational Safety and Health Administration (OSHA) is working with State agencies to compile
work-related injury and illness data from employers within specific industry and employment size specifications. The information
will be used to focus OSHA activities (inspections, outreach, consultations, technical assistance, and leveraging programs) and to
measure the performance of the Agency in meeting its goal of reducing workplace injuries and illnesses.
We are asking for the totals from your 2011 Summary of Work-Related Injuries and Illnesses (OSHA No. 300A), as well as infor­
mation about hours worked and employment at your establishment. The Occupational Safety and Health Act, 29 U.S.C.
§§ 657 & 673, and reporting regulations at 29 C.F.R. Part 1904 authorize OSHA to collect the requested information. Please
note that establishments that fail to submit a completed 2011 survey may be subject to OSHA enforcement actions, including
the issuance of a citation and assessment of penalties.
At this time the Bureau of Labor Statistics (BLS) and its State partners are conducting the 2011 Survey of Occupational Inju­
ries and Illnesses, Part 1 of which solicits information very much like what OSHA is collecting. Be aware that employers who
receive the BLS survey as well as the OSHA data collection form are required by law to respond to both of them, since these
are separate data collection efforts. However, if you have already received the BLS survey, OSHA affords you an option
intended to streamline the effort involved in responding to both collections: That is, you may either (1) complete the
OSHA form in its entirety, in addition to the BLS form, or (2) simply send OSHA a copy of your responses to the BLS
survey (Parts 1A and 1B), which OSHA will accept as your response to the Agency’s collection.
We recognize that responding to our questions may be time consuming for some employers and have made every effort to reduce
the completion time while still obtaining the necessary information. In this spirit, we now provide two means of submitting your
establishment information: (1) by mail or fax, using this hard-copy form, or (2) via the Internet, using a secure electronic version
of this form available on our Web site. Instructions for use of the electronic form are displayed at the Web site. You can access an
electronic survey form by pointing your browser to http://www.osha.gov/form196/collection.htm and then, when prompted,
inputting your establishment-specific ID number and password (provided in the label on the cover of this form). If you choose this
option, use your browser’s print function to print a copy for your records. If you need help in completing the enclosed survey form
or if you have questions, please call the phone number printed on the cover.
OSHA has initiated a comprehensive approach to monitoring and improving data quality. As part of this approach, OSHA will
audit the injury and illness records of a randomly chosen sample of establishments included in this data collection. We will continue
to evaluate this initiative and will build on the lessons learned to improve OSHA’s ability to protect the health and safety of
America’s workers sensibly and appropriately. We invite your comments as we proceed with this effort. Thank you for helping us
collect accurate information and for participating in the effort to make America’s workplaces safer and healthier.
Occupational Safety and Health Administration
U.S. Department of Labor

Who must complete this form?
All establishments that receive this form should complete and return it or respond via the Internet within 30 days, even if they had
no work-related injuries and illnesses recorded on their 2011 OSHA No. 300.

What else do you need?


Information from your 2011 Summary of Work-Related Injuries and Illnesses (OSHA No. 300A).

What do you need to do?


Check the address information printed on the cover. Make any corrections necessary on the hardcopy or Web site.



Complete this form only for the establishment noted on the cover.



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Complete pages 3 and 4. You can either photocopy your OSHA Form 300A or you can transcribe the entries from your
OSHA Form 300A to this survey form.



On the last page, fill in the name of the person we should call with questions and sign the form.



Return this form in the enclosed envelope, fax, or respond via Internet within 30 days of the date your establishment received it.

Establishment Information
Using your completed calendar year 2011 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A), copy the establishment
information into the boxes below. 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, you can estimate using the steps that follow.

1. For the reporting site identified on the cover: Enter
the annual average employment for 2011. (You can
copy this from your OSHA Form 300A.)

2. For the reporting site identified on the cover:
Enter the total hours worked for 2011. (You can
copy this from your OSHA Form 300A.)

Annual average number
of employees for 2011

Total hours worked

by all employees in 2011

Note: Total Hours Worked should exclude vacation, sick leave,
holidays, and other non-work time.

If needed: Steps to estimate employment
STEP 1: Add the number of employees your establish­
ment paid in every pay period during 2011. Include all
employees: full-time, part-time, temporary, seasonal,
salaried, and hourly.
Acme Construction pays its employees 26 times each year.
During 2011,

If needed: Steps to estimate total hours worked
STEP 1: Find the number of full-time employees in your
establishment for 2011.
ABC Company had 15 full-time employees during 2011.

STEP 2: Multiply this number by the number of hours
worked for a full-time employee in a year. This is equal
to the number of full-time hours worked:

In this pay period

Acme paid this many
employees

1 ..................................... 30

2 ..................................... 0

3 ..................................... 35



25 ................................... 36

26 ................................... 32

830 (sum)

ABC Company’s 15 full-time employees worked an average of about
1,760 hours each per year after excluding vacation, sick leave, holi­
days, and other non-work time. (The hours worked for a full-time
employee in a year may be different at your reporting site)

STEP 2: Divide the sum by the number of pay periods
your establishment had in 2011. Include any pay peri­
ods when you had no employees.
Because Acme has 26 pay periods, it would divide its sum by 26.
830 divided by 26 = 31.92

15 (full-time employees) times 1,760 (hours worked by a full-time
employee in a year) equals 26,400 full-time hours.

STEP 3: Add the number of any overtime hours and the
number of hours worked by other employees (part-time,
temporary, seasonal) to the amount in Step 2:
ABC Company’s full time employees worked a total of 1,500 hours
of overtime. In addition, 3 part time employees worked a total of
2,715 hours during 2011. Adding these hours to those from Step 2:

STEP 3: Round the answer to the next highest whole
number. Write the rounded number in the box marked
Annual average number of employees.
Acme would round 31.92 to 32 and write that number in the
box marked Annual average number of employees.

Full-time hours from Step 2
Overtime hours
Part-time hours

+
+

26,400
1,500
2,715

Total hours worked by all employees in 2011 =

30,615

3. Check any conditions that might have affected your annual average number of employees or total hours
worked during 2011:
 Strike or lockout
 Shutdown or layoff
 Seasonal work
 Natural disaster or adverse weather conditions

 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

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Did you have ANY occupational injuries or illnesses during 2011?


Yes. Go to the next section, Summary of Work-Related Injuries and Illnesses, 2011.



No. Go to Sign and return this form below.

Summary of Work-Related Injuries and Illnesses, 2011
Using your completed calendar year 2011 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A):
1. Copy the establishment summary information into the spaces below.
2. If you prefer, you may enclose a photocopy of your Summary of Work-Related Injuries and Illnesses (OSHA Form 300A).
3. If any total is zero on your OSHA Form 300A, write “0” in that total’s space below.

Number of Cases
Copy these totals
from columns
(G), (H), (I), and (J):

Number of Days
Copy these totals
from columns (K)
and (L):

Total number
of cases with
days away
from work
(column H)

Total number
of deaths
(column G)

Total number
of days away
from work
(column K)

Total number
of cases with
job transfer or
restriction
(column I)

Total number
of other
recordable
cases
(column J)

Total number of
days of job transfer
or restriction
(column L)

Injury and Illness Types
Total number of . . .
from column (M)

(1) Injuries

(4) Poisonings

(2) Skin disorders

(5) Hearing loss

(3) Respiratory conditions

(6) All other illnesses

Sign and return this form
Fill in the name, title, phone number and fax number of the person we should call with questions about this form. Then sign and date
the form.
Printed name
Signature

(
)
Telephone number
Title

(
)
Ext. Fax number

E-mail address (optional)
Today’s date

Use the envelope included with this packet to mail the original form to us. If the return envelope is missing, send the package to the
Return Address on the front cover. Remember to keep a photocopy for your records.

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