BLS 9300FAX Fax Form 2021 Example

Survey of Occupational Injuries and Illnesses

AK_2021 with DART

OMB: 1220-0045

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

S urvey of Occupational Injuries
and Illnesses, 2021

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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

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Contact Name and Title (please print) Telephone Number (ext) Fax Number

( ) - ( ) -

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1 Enter the annual average number of employees for 2021.

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


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

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Yes Complete Section 2 below.

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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.


  1. Was employee treated in an emergency room? yes no

  2. Was employee hospitalized overnight as an in-patient? yes no

8. Time employee began work: __________ am pm

Text Box 26_0 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.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSurvey of Occupational Injuries
Authormccarthy_w
File Modified0000-00-00
File Created2021-12-27

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