BLS 9300FAX Fax Form 2021 Example

U.S. Department of Labor, Bureau of Labor Statistics OMB No. 1220-0045

S urvey of Occupational Injuries
and Illnesses, 2021

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 2021.

2. Enter the total hours worked by all employees for 2021.

3. Did you have ANY work-related injuries or illnesses during 2021?

 Yes Complete Section 2 below.

 No Please fax this form to (907) 465-4506.

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		________		(4) Poisonings		________
(2) Skin disorders		________		(5) Hearing loss		________
(3) Respiratory conditions		________		(6) All other illnesses		________

BLS-9300 FAX

Injury and Illness Case Form

If you had cases in 2021 with days away from work (Column H in Section 2 on Page 1) or days of job transfer or restriction (Column I in Section 2 on Page 1), please complete one Injury and Illness Case Form or each case. We have designed this survey to ensure that you do not have to report more than 8 cases. If you have more than 8 cases, please contact the office whose number appears on the front of the survey form.

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)      	Job title (Column C)      	Date of injury or onset of illness (Column D)    /    /21 month day year	Number of days away from work (Column K)      	Number of days of job transfer or restriction (Column L)      

Tell us about the Employee

1. Check the category which best describes the employee's regular type

of job or work: (optional)

 Office, professional, business,	 Healthcare
or management staff	 Delivery or driving
 Sales	 Food service
 Product assembly,	 Cleaning, maintenance
product manufacture	of building, grounds
 Repair, installation or service	 Material handling (e.g.,stocking,
of machines, equipment	loading/unloading, moving, etc.)
 Construction	 Farming

_ 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

^{Tell us about the Incident}

_{Answer the questions below or attach a copy of a supplementary} ^{document that answers them.}

6. Was employee treated in an emergency room? _{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 }

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.