CFOI -1 Census of Fatal Occupational Injuries Report

Bureau of Labor Statistics
Census of Fatal
Occupational Injuries Report

U.S. Department of Labor

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. Per the Cybersecurity
Enhancement Act of 2015, Federal information systems are protected from malicious activities through
cybersecurity screening of transmitted data.
ID

OMB No.
1220-0133

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 by email to [email protected]. 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:
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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)

2. Social Security Number:
3. Direct employer at the time of the incident (company that paid deceased’s wages):
(Company name)
(Street address)
(City)
(

(Area code)

(State)
)

(Zip code)

(Phone number)

BLS CFOI - 1

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4. Date of birth:
5. Ethnicity and race:

(Month)

(Day)

(Year)

(Select one or more: if unknown leave blank)

 American Indian or Alaska Native
 Black or African American
 Native Hawaiian or Other Pacific Islander
6. Gender:  Male

ID

 Female

 Asian
 Hispanic or Latino
 White

 Non-binary or another gender identity

 Unknown

7. 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
 incorporated
 unincorporated
(Check only ONE):
 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
2. Occupation of deceased at the time of the incident: (Examples include: cashier, drywall installer,
farm foreman)
3. How long did the deceased work in the position held at the time of the incident?
years

months (if less than 1 year)

4. Which of the following best describes the type of employer by which the deceased
was directly employed? (Check only ONE)
 a private company or self-employed
 a local government agency
 a state government agency

 a federal government agency
 a foreign or international government agency
 other governmental body, such as a regional
or interstate commission

5. 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.)

6. 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

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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
 Yes

If YES, where did the incident occur?






in a work area
in the company parking lot
on an outside walkway
in a recreational area

 in a hallway, stairway, rest room, or cafeteria
 some other place (Please specify):
 don’t know

6. 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:
a. 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.)

b. Which of the following best describes the type of employer for this different company?
(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

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7. What was the deceased doing at the time of the incident? (Mark ALL that apply.)

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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.)

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
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
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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:
2. Your job title:
3. Your daytime phone number:
4. Date you completed this form:

(
)
(Area code)
(Month)

(Phone number)
(Day)

(Year)