Bls9300 Fax Soii 2016

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

Survey of Occupational Injuries
and Illnesses, 2016
Alabama Fax Response Form
Send to (334) 242-2543
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
01 - 12345678901234567890 - 10

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 2016.
2. Enter the total hours worked by all employees for 2016.
3. Did you have ANY work-related injuries or illnesses during 2016?
 Yes
Complete Section 2 below.
 No
Please fax this form to (334) 242-2543.
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

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)

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

Injury and Illness Case Form
Tell us about each 2016 work-related injury or illness case if it resulted in days away from work (Column H in Section 2 on Page 1).
If you are reporting for a private industry establishment whose six-digit NAICS code begins with: 312, 452, 492, 562, 622, or 721,
also tell us about each case with days of job transfer or restriction (Column I in Section 2 on Page 1). Your NAICS code can be found
on the front of your survey instruction sheet. One Injury and Illness Case Form should be completed for each injury or illness case.
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 day

Number of days
away from work
(Column K)

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

/16
year

Tell us about the Employee

Tell us about the Incident

1. Che ck 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:____________________







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

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
6. Was employee treated in an emergency room?

,

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? T ell 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.”

NO TE: 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

year

12. What was the injury or illness? T ell 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.”

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

day

year

OR check length of service at establishment when incident
occurre d:

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

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.

5. Employee’s gender:
Male
Female




Thank you for your participation. Please fax your completed forms to (334) 242-2543.
For office use
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