Attachments

CFOI OMB 070913 - Attachments 2013.doc

Census of Fatal Occupational Injuries

Attachments

OMB: 1220-0133

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Attachment 1A

Census of Fatal Occupational Injuries

Data Elements

(Collected and Coded by States, Cities, and Territories)


  • Reference State and year

  • Injury or illness

  • State of residence

  • Date of birth

  • Age, Source document associated with age

  • Race, Source document associated with race

  • Hispanic or Latino origin, Source document associated with Hispanic or Latino Origin

  • Gender, Source document associated with gender

  • Industry code and narrative (North American Industrial Classification System (NAICS)), Source document associated with industry

  • Ownership (Federal, State, local, foreign, or other government; or private sector), Source document associated with ownership

  • Establishment size class

  • Occupation code and narrative (Standard Occupational Classification (SOC)), Source document associated with occupation

  • Employee status (Active duty military, self-employed, family business, working for pay, volunteer, institutionalized individuals, unknown), Source document associated with employee status

  • State of employment

  • Date of injury and death

  • State of injury and death

  • County of injury

  • Time of incident

  • Nature of injury/illness (BLS Occupational Injury and Illness Classification System (OIICS))

  • Part of body (BLS OIICS)

  • Primary and secondary source of injury/illness (BLS OIICS)

  • Event or exposure (BLS OIICS), Source document associated with event or exposure

  • Worker activity

  • Location type (farm, street, mine, etc.)

  • How the injury/illness occurred (narrative description; up to 500 characters)

  • Source documents requested and received

  • Link code (links fatalities resulting from a single incident)

  • Birthplace—country

  • Medical complications code

  • Impairments

  • Contractor information (whether worker was employed by a contractor and contracting agency’s industry code, industry narrative, and ownership)*

Optional data elements

  • Length of time in occupation**/current position/with employer**

  • Usual lifetime industry/occupation**

  • Time workday began, Time of incident before time workday began*

  • Cause of injury/illness (ICD-10 external cause codes)**

  • Processing comments

  • Union status (whether worker was a member of a union)*

  • Confined space incident (whether worker was in a confined space)*

  • Alcohol/drug, narrative (whether the decedent was under the influence of drugs or alcohol, and which ones specifically)*

  • Disaster codes (whether the death was a result of a CFOI-designated disaster)*

  • Seat belt (whether decedent was wearing a seat belt)*



*Added beginning with data for 2011

**Deleted beginning with data for 2011

Attachment 1B

Census of Fatal Occupational Injuries

Research File Data Elements


The following data elements are included on the CFOI Research File for each fatality record. This file is given to qualified researchers who sign a Letter of Agreement and agree to comply with BLS confidentiality policy.


  1. Year of death

  2. Region designation for State code

  3. Report ID (unique 5-digit code)

  4. Injury (illnesses are maintained as a separate file)

  5. Race

  6. Gender

  7. Industry (based on the Standard Industrial Classification (SIC) Manual /
    North American Industrial Classification System beginning with data for 2003)

  8. Ownership (federal, state or local government; private)

  9. Occupation (based on the 1990 Census of Population Occupational Classification System /
    Standard Occupation Classification (SOC) beginning with 2003 data)

  10. Employee status (wage and salary, self-employed, etc.)

  11. Nature of injury/illness (based on the BLS Occupational Injury and Illness
    Classification Structures (OIICS), which was adopted as a National standard by ANSI Z16.2 in September 1995.

  12. Part of body affected (BLS OIICS)

  13. Source of injury (BLS OIICS)

  14. Secondary source of injury (BLS OIICS)

  15. Event or exposure (BLS OIICS)

  16. Worker activity (at the time of incident)

  17. Hispanic origin

  18. Location of incident (farm, street, mine, etc.)

  19. Age (10-year intervals starting with less than 20)

  20. Date of injury (day of the week, month, and year)

  21. Days survived (number of days between injury and death)

  22. Born in foreign country (name of continent)

  23. Establishment sizes (5 employment size groups)

  24. Length of time with employer (in years)

  25. Urban or rural area

  26. Time of incident (to the nearest hour)

  27. How the injury occurred (narrative description up to 500 characters)

  28. Confined space incident*

  29. Contractor information (whether worker was employed by a contractor and contracting agency’s industry code, industry narrative, and ownership)*


Additional data elements requested by NIOSH:

  1. State codes

  2. Date of birth

  3. Date of death

  4. Death certificate identification number

  5. Narrative industry and occupation description

*Added beginning with data for 2011

Followback questionnaire: Informant letter (CFOI-1) Attachment 2A




---------------------------------------------------------------------------------------------------------------------



State letterhead



---------------------------------------------------------------------------------------------------------------------


Dear:


It is with sincere regret that we must request your assistance during this difficult time. We have learned of [decedent's name]'s death and that it may have occurred at work. We request your assistance in providing information that will help us to better understand the circumstances surrounding the incident. Please take a few minutes to complete this important information using the enclosed form.


What we are asking:


We are committed to minimizing your effort in providing the requested information. Therefore, we have completed all of the information that is available to us. To ensure accuracy and completeness of information, we request that you:


  1. check our entries and make any necessary corrections to the information reported;

  2. complete any missing information that you have available; and

  3. indicate which, if any, information you are unable to provide by writing in ‘NA.’


If you prefer, you may provide the requested information by telephone. Information about whom to contact is provided below.


Reason for our request:


The purpose of this request is to obtain a better understanding of the hazards employees face in the workplace. Complete and accurate information on work-related injuries and fatalities is essential for developing effective strategies that may reduce the number of work-related injuries.


Authorizations for collecting information:


The information is being collected by the [State Agency] in cooperation with the Bureau of Labor Statistics of the U.S. Department of Labor. The Census of Fatal Occupational Injuries is authorized by the Occupational Safety and Health Act of 1970 (Public Law 91-596) and has been approved by the Office of Management and Budget (OMB Number 1220-0133).


Confidentiality of your information:


Your voluntary cooperation is needed to ensure the information we collect is complete and accurate. 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.


Summary results will be made public to inform workers and employers about hazards in the workplace. Under written agreements to protect confidentiality and security of identifying information, a detailed data file will be made available to authorized researchers for conducting specific research projects. No personal or company identifiers will be released. Although we have taken every precaution to ensure the confidentiality of the information that you provide, it may be possible to recognize catastrophic or well-publicized events from the BLS releases.


To return your completed form:


We have enclosed an envelope to assist you in returning the form as soon as possible. If you have any questions about the form or would like to report the information by telephone, please contact [name and telephone number to be inserted by the individual State].


Thank you very much in advance for your assistance in providing valuable information that will help make workplaces safer.


With deepest sympathy,


[State agency official]


Enclosures


Followback questionnaire: Letter for Employer or Administrative Agency (CFOI-1)



---------------------------------------------------------------------------------------------------------------------



State letterhead



---------------------------------------------------------------------------------------------------------------------


Dear:


We have learned of [decedent's name]'s death and that it may have occurred at work. We request your assistance in providing information that will help us to better understand the circumstances surrounding the incident. Please take a few minutes to complete this important information using the enclosed form or by sending us a copy of the report describing the incident.

What we are asking:


We are committed to minimizing your effort in providing the requested information. Therefore, we have completed all of the information that is available to us. To ensure accuracy and completeness of information, we request that you:


  1. check our entries and make any necessary corrections to the information reported;

  2. complete any missing information that you have available; and

  3. indicate which, if any, information you are unable to provide by writing in ‘NA.’


If you prefer, you may provide the requested information by telephone. Information about whom to contact is provided below.


Reason for our request:


The purpose of this request is to obtain a better understanding of the hazards employees face in the workplace. Complete and accurate information on work-related injuries and fatalities is essential for developing effective strategies that may reduce the number of work-related injuries.


Authorizations for collecting information:


The information is being collected by the [State Agency] in cooperation with the Bureau of Labor Statistics of the U.S. Department of Labor. The Census of Fatal Occupational Injuries is authorized by the Occupational Safety and Health Act of 1970 (Public Law 91-596) and has been approved by the Office of Management and Budget (OMB Number 1220-0133).


Confidentiality of your information:


Your voluntary cooperation is needed to ensure the information we collect is complete and accurate. 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.


Summary results will be made public to inform workers and employers about hazards in the workplace. Under written agreements to protect confidentiality and security of identifying information, a detailed data file will be made available to authorized researchers for conducting specific research projects. No personal or company identifiers will be released. Although we have taken every precaution to ensure the confidentiality of the information that you provide, it may be possible to recognize catastrophic or well-publicized events from the BLS releases.


To return your completed form:


We have enclosed an envelope to assist you in returning the form as soon as possible. If you have any questions about the form or would like to report the information by telephone, please contact [name and telephone number to be inserted by the individual State].


Thank you very much in advance for your assistance in providing valuable information that will help make workplaces safer.


Sincerely,


[State agency official]


Enclosures





















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.




Return to:




For assistance call:



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?


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

  • Y 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

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


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


9 . 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)

Letter requesting source documents



---------------------------------------------------------------------------------------------------------------------



State letterhead



---------------------------------------------------------------------------------------------------------------------


Dear:


The Occupational Safety and Health Act of 1970 (PL 91-596) requires the Secretary of Labor to develop and maintain an effective program of collection, compilation, and analysis of occupational safety and health statistics. In response to the need for complete, accurate, and timely data for occupational fatalities occurring in the United States, the Bureau of Labor Statistics (BLS), in cooperation with (State Agency), implemented the Census of Fatal Occupational Injuries (CFOI) in 1992. The CFOI has been approved by the Office of Management and Budget (OMB Number 1220-0133).


To ensure complete, up-to-date fatality information, we collect data from various sources:


  • death certificates;

  • Federal and State workers’ compensation reports;

  • reports to Federal and State regulatory agencies;

  • medical examiner and autopsy reports;

  • highway and police reports; and

  • other reports available to State agencies.


We would appreciate your assistance in collecting these data. We would like to receive, on a flow basis, copies of any documents or reports you receive concerning work-related fatalities. We may also request documents for fatalities identified by other sources as work-related to obtain additional information. We will use information contained on these documents to determine if the fatality occurred while the person was in a work status. The worker’s name, Social Security Number, date of birth, date of injury, date of death, and employer’s name are needed to match reports from other sources to ensure that each fatality is counted only once.


Your voluntary cooperation is needed to ensure the information we collect is complete and accurate. 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.


Summary results will be made public to inform workers and employers about hazards in the workplace. Under written agreements to protect confidentiality and security of identifying information, a detailed data file will be made available to authorized researchers for conducting specific research projects. No personal or company identifiers will be released. Although we have taken every precaution to ensure the security of information collected under a pledge of confidentiality, it may be possible to recognize catastrophic or well-publicized events from the BLS releases.


[We would like to meet with you at your convenience to discuss this program in more detail.] Please call (State contact name) at (telephone number) if you have any questions regarding the fatality census or would like to schedule an appointment with us. If a more formal arrangement is needed to obtain these documents, please let us know and we would be happy to discuss the options with you, including a Memorandum of Understanding between our agencies.


Sincerely yours,


(State official’s name)





































FAX requesting death certificates


---------------------------------------------------------------------------------------------------------------------



State letterhead



---------------------------------------------------------------------------------------------------------------------


FAX TRANSMISSION


**********************************************************************

This document and any attachments are confidential and intended solely
for the individual or entity to whom they are addressed. If you have
received this fax in error, destroy it immediately.

**********************************************************************


Date:


Please deliver to: [Name, address, fax, and phone]








Total number of pages including this sheet: __________



Please fax or mail Death Certificates for the persons listed below to:


[ Name, address, fax, and phone of CFOI state agency ]





Thank you for your time.



[Name of CFOI contact]



Name SS# Date of death


John Doe xxx-yy-zzzz mm/dd/yyyy

Jane Smith yyy-xx-aaaa mm/dd/yyyy


End of list

File Typeapplication/msword
File TitleAttachment 2A
AuthorOCWC
Last Modified Bykincaid_n
File Modified2013-07-17
File Created2013-07-17

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