Soii_informed_consent_letter

(State), in cooperation with the Bureau of Labor Statistics (BLS), would like to publish statistical tabulations in (industry name) (Industry code, TEI). In preparing the results of the survey, however, we found that your company is a major reporter for your industry in ____ (State). Thus, publishing certain tabulations might permit information about your establishment to be inferred by public users of the data. In accordance with BLS policy on confidentiality, we will not publish those tabulations unless you provide written permission to do so.

Therefore, we request your permission to publish tabulations that might permit information about your establishment to be inferred by the public. Space is provided at the bottom of this page for you to provide this permission. The published tabulations would not include your company name, address, or any other information that would directly identify your establishment. Consent can be withdrawn at any time, but those data published during the period of consent cannot be retracted.

We are grateful for your participation and cooperation as it is essential to the success of our program. Safety and health professionals, employers, and the public will gain important occupational injury and illness information that will improve the working conditions of employees and may help decrease the occurrence of injuries and illnesses in the workplace. If you have any questions, please call of our Office at (State phone number)

Sincerely,

(Name and Title)

__________________________________________________________________________

On behalf of (company, establishment name), I hereby authorize (State) to publish statistical tabulations for the Survey of Occupational Injuries and Illnesses in the above referenced industry. Authorization is granted (please check one):

( ) for five consecutive Survey years (20__ through 20__);

( ) for Survey year 20__ only.

This authorization is provided solely for State publication of statistical tabulations. Release of the information for any other purpose, or in any other manner, is neither given nor implied.

(Signature) (Date)

(Printed Name)

(Title)