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

Census of Fatal Occupational Injuries

BLS CFOI-1

Census of Fatal Occupational Injuries - State, local, and tribal government

OMB: 1220-0133

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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


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.




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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)


  1. Social Security Number: ______________________


  1. Direct employer at the time of the incident (company that paid deceased’s wages):


_____________________________________________________________________________

(Company name)

_____________________________________________________________________________

(Street address)

_____________________________________________________________________________

(City) (State) (Zip code)

(___________________) ___________________________________________________

(Area code) (Phone number)

BLS CFOI - 1

___ ____

ST ID


  1. Date of birth: ________________________________________________________________

(Month) (Day) (Year)


  1. Ethnicity and race: (Select one or more: if unknown leave blank)


American Indian or Alaska Native Asian

Black or African American Hispanic or Latino

Native Hawaiian or Other Pacific Islander White


  1. Gender: Male Female


  1. 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, or owner of a 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


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


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

Shape2 Shape1

years months (if less than 1 year)



  1. 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

  1. Describe the nature of the business or the main type of activity performed by the direct employer at the establishment. (Examples include: manufacturer of storage batteries, grocery store, computer programming services, etc.)


________________________________________________________________________________






___ ____

ST ID


  1. On average, about how many persons work for the direct 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 direct employer's premises?


  • No

  • YShape3 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


  1. Was the site where the employee was working at the time of the incident under the control of his/her direct employer, or was the employee working at a site where a different company exercised overall responsibility for the operations at the site?


Direct employer

Shape4 Different company If different company:

  1. Describe the nature of the business or the main type of activity performed by this different company at the establishment. (For example, a plumber for a repair firm was killed while working at a restaurant to fix a dishwasher. The direct employer is the repair firm since it paid the plumber’s wages. The different company is the restaurant since it exercised overall responsibility for the operations at the site)


___________________________________________________________________________


  1. Which of the following best describes the type of employer this different company is? (Check only ONE)

a private company 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


7. 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


8Shape5 . What time did the incident occur? Check only ONE: AM PM


9Shape6 . What time did the deceased's workday

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


10. 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): ____________________________________________________


11. 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: _____________________________________________________________________


  1. Your job title: ___________________________________________________________________

  2. Your daytime phone number: (__________) _____________________________________

(Area code) (Phone number)


  1. Date you completed this form: ____________________________________________________

(Month) (Day) (Year)


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