Attachment 2A - Followback questionnaire - private industry

Followback questionnaire: Letter for Employer or Administrative Agency (CFOI-1)

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State letterhead

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Dear:

We have learned of [decedent's name]'s death and that it may have occurred at work. We request your assistance in providing information that will help us to better understand the circumstances surrounding the incident. Please take a few minutes to complete this important information using the enclosed form or by sending us a copy of the report describing the incident.

What we are asking:

We are committed to minimizing your effort in providing the requested information. Therefore, we have completed all the information that is available to us. To ensure accuracy and completeness of information, we request that you:

1. check our entries and make any necessary corrections to the information reported;

2. complete any missing information that you have available; and

3. indicate which, if any, information you are unable to provide by writing in ‘NA.’

If you prefer, you may provide the requested information by telephone. Information about whom to contact is provided below.

Reason for our request:

The purpose of this request is to obtain a better understanding of the hazards employees face in the workplace. Complete and accurate information on work-related injuries and fatalities is essential for developing effective strategies that may reduce the number of work-related injuries.

Authorizations for collecting information:

The information is being collected by the [State Agency] in cooperation with the Bureau of Labor Statistics of the U.S. Department of Labor. The Census of Fatal Occupational Injuries is authorized by the Occupational Safety and Health Act of 1970 (Public Law 91-596) and has been approved by the Office of Management and Budget (OMB Number 1220-0133).

Confidentiality of your information:

Your voluntary cooperation is needed to ensure the information we collect is complete and accurate. 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 (44 U.S.C. 3572) 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.

Summary results will be made public to inform workers and employers about hazards in the workplace. Under written agreements to protect confidentiality and security of identifying information, a detailed data file will be made available to authorized researchers for conducting specific research projects. No personal or company identifiers will be released. Although we have taken every precaution to ensure the confidentiality of the information that you provide, it may be possible to recognize catastrophic or well-publicized events from the BLS releases.

To return your completed form:

We have enclosed an envelope to assist you in returning the form as soon as possible. If you have any questions about the form or would like to report the information by telephone, please contact [name and telephone number to be inserted by the individual State].

Thank you very much in advance for your assistance in providing valuable information that will help make workplaces safer.

Sincerely,

[State agency official]

Enclosures