Form NIST-985 Injury / Illness / Exposure Assessment

OMB Control Number: 0693-0080 Expiration Date: 08/31/2024
U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

NIST-985
(REV. 4-2021)
NIST P 7100.00

INJURY/ILLNESS/EXPOSURE ASSESSMENT
Name:

Position Title:

Div.#:

Mailing Address:

Incident Location:

Ext.:

Date/Time of Incident:

Date/Time of Treatment:

Describe Briefly What Happened (as related by patient):

**Chemical exposure/involvement. Name of Material(s):
Indicate personal protective equipment used:
Supervisor/Sponsor Name:

Safety Glasses

Goggles

Respirator

Gloves

Other:

Supervisor/Sponsor Ext.:

Has he/she been notified?
Yes

Comments of Attending Physician/Nurse (extent of injuries, condition, etc.):

Patient Referred to:

Incident Classification:

Medical Treatment (on-site)

Medical Treatment (off-site)

Attending Physician/Physician Assistant/Nurse (Signature):

First Aid

Repeat First Aid

Date:

Comments/Follow-up:

Which OWCP Forms were given?:

CD-137

None

CA-1

CA-2

CA-16

CA-17

OWCP 1500

No

OMB Control Number: 0693-0080 Expiration Date: 08/31/2024

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be
subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork
Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved
OMB Control Number for this information collection is 0693-0080. Without this approval, we could not conduct this
information collection. Public reporting for this information collection is estimated to be approximately 10 minutes
per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the information collection. All responses to this information
collection are voluntary. Send comments regarding this burden estimate or any other aspect of this information
collection, including suggestions for reducing this burden to the National Institute of Standards and Technology, Attn:
Stephen Banovic, [email protected].

PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why the U.S. Department
of Commerce (the Department), National Institute of Standards and Technology (NIST) is requesting the
information on this form.
AUTHORITY:
The collection of this information is authorized under The National Institute of Standards and Technology Act,
as amended, 15 U.S.C. 271 et seq. (which includes Title 15 U.S.C. 272) and section 12 of the Stevenson-Wydler
Technology Innovation Act of 1980, as amended, 15 U.S.C. 3710a. Includes the following, with all revisions
and amendments: 5 U.S.C. 301; 44 U.S.C. 3101; E.O. 12107, E.O. 13164, 41 U.S.C. 433(d); 5 U.S.C. 5379; 5
CFR Part 537; DAO 202-957; E.O. 12656; Federal Preparedness Circular (FPC) 65, July 26, 1999; DAO 210110; Executive Order 12564; Public Law 100-71, dated July 11, 1987. Executive Orders 12107, 12196, and
12564 and 5 U.S.C. chapters 11, 33, and 63.
PURPOSE:
The Office of Safety, Health, and Environment (OSHE) supports the National Institute for Standards and
Technology in carrying out its mission safely and in maintaining safety as an integral core value and vital part
of the NIST culture. The NIST Health Unit will use this information to record medical or health information for
individuals seeking medical care on NIST campus; for recording of medical or safety equipment or incidents; to
refer information required by applicable law to be disclosed to a Federal, State, or local public health service
agency, concerning individuals who have contracted certain communicable diseases or conditions. Such
information is used to prevent further outbreak of the disease or condition; to disclose information to the
appropriate Federal, State, or local agency responsible for investigation of an accident, disease, medical
condition, or injury as required by pertinent legal authority; to disclose information, when an individual to
whom a record pertains is mentally incompetent or under other legal disability, to any person who is responsible
for the care of the individual, to the extent necessary; to disclose to the Office of Workers' Compensation
Programs in connection with a claim for benefits filed. Disclosure of this information is also subject to all the
published routine uses as identified in the Privacy Act System of Records Notices:
Commerce/DEPT-18: Employees Personnel Files Not Covered by Notices of Other Agencies
OPM/GOVT-10: Employee Medical File System Records.
ROUTINE USES:
The information solicited on this form may be made available as a “routine use” pursuant to 5 U.S.C. §
552a(a)(7) and (b)(3). The information may be made available to other federal agencies to assist the
Department in connection with NIST’s management of the purposes stated above; or for other authorized
routine uses.
A complete list of the routine uses can be found in the system of records notice associated with this form,
“COMMERCE/DEPT-23: Information Collected Electronically in Connection with Department of Commerce
Activities, Events, and Programs; and COMMERCE/DEPT-13: Investigative and Security Records. These
system of records notices can be found on the Department's website at

https://www.osec.doc.gov/opog/privacyact/privacyact_sorns.html and OPM/GOVT-10: Employee Medical File
System Records at https://www.opm.gov/information-management/privacy-policy/sorn/opm-sorn-govt-10employee-medical-file-systems-records.pdf
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION:
Providing this information is voluntary. However, failure to provide the requested information may result in an
inability for NIST to process, review, and/or act on such requests. In limited circumstances, NIST may
authorize the submission of the requested information via paper forms pursuant to the requirements in 15 CFR
748.1(d).

NIST-985 (REV. 4-2021)