U.S. Department of Labor, Bureau of Labor Statistics OMB No. 1220-0045
S
urvey
of Occupational Injuries
and Illnesses, 2020
Alaska
Fax Response Form
Send to (907) 465-4506
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 |
02 - 12345678901234567890 - 10 Establishment ID Number (from front of survey instructions)
Company Name and Report For (from front of survey instructions) Today’s Date
Contact
Name and Title
(please print)
Telephone Number
(ext) Fax Number
( ) - ( ) -
1 Enter the annual average number of employees for 2020.
2. Enter the total hours worked by all employees for 2020.
3. Did you have ANY work-related injuries or illnesses during 2020?
Yes Complete Section 2 below.
No Please fax this form to (907) 465-4506.
Section 2: Summary of Work-Related Injuries and Illnesses |
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.
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.
If any total is zero on your OSHA Form 300A, write “0” in that space below.
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 |
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Total number of deaths |
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Total number of cases with days away from work |
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Total number of cases with job transfer or restriction |
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Total number of other recordable cases |
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____________________ |
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_________________ |
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_________________ |
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_________________ |
(G) |
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(H) |
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(I) |
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(J) |
Number of Days |
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Total number of days away from work |
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Total number of days of job transfer or restriction |
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____________________ |
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__________________ |
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(K) |
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(L) |
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Injury and Illness Types |
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Total number of … |
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(M) |
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(1) Injuries |
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________ |
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(4) Poisonings |
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________ |
(2) Skin disorders |
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________ |
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(5) Hearing loss |
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________ |
(3) Respiratory conditions |
________ |
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(6) All other illnesses |
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________ |
BLS-9300 FAX
Injury and Illness Case Form
Tell us about each 2020 work-related injury or illness case if it resulted in days away from work (Column H 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.
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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)
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Job title (Column C)
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Date of injury or onset of illness (Column D)
/ /20 month day year |
Number of days away from work (Column K)
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Number of days of job transfer or restriction (Column L)
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Tell us about the Employee
1. Check the category which best describes the employee's regular type of job or work: (optional)
Other:____________________
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
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 year
4. Employee’s date hired: ______/______/______ month day year OR check length of service at establishment when incident occurred:
Less than 3 months From 3 to 11 months From 1 to 5 years More than 5 years
5. Employee’s gender: Male Female
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Tell us about the Incident
Answer the questions below or attach a copy of a supplementary document that answers them.
Was employee treated in an emergency room? yes no
Was employee hospitalized overnight as an in-patient? yes no
8. Time employee began work: __________ am pm
9.
Time of event:
__________ am
pm
OR
Event occurred: (optional) before during after work shift
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.”
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.”
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.”
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.
Check if time cannot
be determined
Thank you for your participation. Please fax your completed forms to (907) 465-4506.
For office use
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Survey of Occupational Injuries |
Author | mccarthy_w |
File Modified | 0000-00-00 |
File Created | 2021-01-13 |