Download FAX Forms

If there were few or no work-related injuries and illnesses at your sampled establishment in calendar year 2012, you may respond to us via FAX. You may select a form below based on the location of your establishment.

State Code State Name
01 Alabama
02 Alaska
04 Arizona
05 Arkansas
06 California
08 Colorado
09 Connecticut
10 Delaware
11 District of Columbia
12 Florida
13 Georgia
66 Guam
15 Hawaii
16 Idaho
17 Illinois
18 Indiana
19 Iowa
20 Kansas
21 Kentucky
22 Louisiana
23 Maine
24 Maryland
25 Massachusetts
26 Michigan
27 Minnesota
28 Mississippi
29 Missouri
30 Montana
31 Nebraska
32 Nevada
33 New Hampshire
34 New Jersey
35 New Mexico
36 New York
37 North Carolina
38 North Dakota
39 Ohio
40 Oklahoma
41 Oregon
42 Pennsylvania
43 Puerto Rico
44 Rhode Island
45 South Carolina
46 South Dakota
47 Tennessee
48 Texas
49 Utah
50 Vermont
51 Virginia
52 Virgin Islands
53 Washington
54 West Virginia
55 Wisconsin
56 Wyoming

 

Last Modified Date: January 8, 2014