Instructions to Complete the 8-Page Form

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Front Page Survey Label Page2 Page 3Section 1 Section 2
Front Page Label Page 2 Page 3

 

Page4 Page 5 Page6 - 7Tell us about the Case Tell us about the Employee Tell us about the Incident BLS Use Only Page 8Section 4 Section 5
Page 4 Page 5 Page 6 - 7 Page 8

 

Front Page

The front page of the survey will display a mailing label, the Office of Management and Budget statement regarding the length of time it will take to complete the survey, as well as the BLS confidentiality pledge.

OMB burden statement

We estimate it will take you an average of 24 minutes to complete this survey (ranging from 10 minutes to 5 hours per package), including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing this information. If you have any comments regarding the estimates or any other aspect of this survey, including suggestions for reducing this burden, please send them to the Bureau of Labor Statistics, Occupational Safety and Health Statistics (1220-0045), 2 Massachusetts Avenue, N.E., Washington, DC 20212. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS.

BLS confidentiality pledge

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.

Label

Survey Label

The address of the State or federal agency that is collecting your survey is presented in the upper left of the label. (This address appears through the left hand window of the outgoing mail envelope when the survey is sent to you.) This section also includes Your establishment ID (needed for on-line collection or e-mail collection of your data) and the location(s) for which the survey should be completed. (Listed under 'Report for:')

In the Upper Right of the label are phone and fax numbers you can use for assistance.

Your user ID and temporary password for on-line completion of the survey are located in the Bottom Right section, along with your NAICS Industry code. The remaining items in this portion of the label are for survey use only.

Your company address is presented in the bottom left of the label. If you need to make changes to your company address, you can note those changes on the front of the survey.

Page 2

This page presents the steps you need to take to complete the survey.

Step 1: Complete this survey only for the establishment(s) noted on the front cover under "Report for: ." If you are unsure, please call the number(s) listed on the front of this form in the "For Help:" section.

Step 2: Check "Your Company Name" printed on the front cover. Make any necessary corrections directly on the front cover.
Step 3: Refer to your establishment's OSHA Forms for Recording Work-Related Injuries and Illnesses. Copies of these forms were mailed to you in late 2012.
  • If you had no work-related injuries and illnesses in 2013, answer all questions in Section 1 and 4 of the survey.
  • If you had at least one work-related injury or illness in 2013, answer all questions in Sections 1, 2, and 4 of the survey.
  • Report cases with Days Away From Work (with or without days of job transfer or restriction) in Section 3.
  • Report cases with Job Transfer or Restriction (without days away from work) in Section 3 if your NAICS code begins with these numbers: 238, 311, 444, 481, 493, or 623 (see mailing label example for NAICS code location).
Step 4: In case we have questions, write the name of the person who completed this survey in Section 4: Contact Information, on the last page of this survey.
Step 5: Return this survey and any attachments in the enclosed envelope within 30 days of the date your establishment received it.

Page 3 - Section 1

  1. Enter your user ID in item 1. Your user ID is printed on the front of your form.
  2. Enter your annual average number of employees during 2013 in item 2.
  3. Enter your total hours worked by all employees during 2013 in item 3.
  4. Check any unusual circumstances that might have occurred during 2013 to affect your answers in items 2 or 3. For example, your number of employees grew during 2013 because of growth or the number of hours worked by your employees fell during 2013 because of a strike.
  5. Check whether your establishment experienced any work-related injuries or illnesses during 2013 in item 5.

Page 3 - Section 2

  1. Refer to the OSHA Forms for Recording Work-Related Injuries and Illnesses for the location referenced on the front cover of the survey under "Report for this Location." If you prefer, you may enclose a photocopy of your Summary of Work-Related Injuries and Illnesses (OSHA Form 300A).
  2. If more than one establishment is noted on the front cover of this survey, be sure to include the OSHA Form 300A for all of the specified establishments.
  3. If any total is zero on your OSHA Form 300A, write "0" in that total's space below.
  4. The total Number of Cases recorded in G + H + I + J must equal the total Injury and Illness Types recorded in M (1 + 2 + 3 + 4 + 5 + 6).

Page 4

Steps to calculate your annual average number of employees for 2013 and to estimate your total hours worked for 2013 are presented on page 4.

Page 5 - Section 3

  1. If you had NO cases with days away from work (Column H) and NO cases with days of job transfer or restriction (Column I), please proceed to Section 4: Contact Information.
  2. If you had cases with days away from work (Column H) and/or cases with days of job transfer or restriction only (Column I), please complete Section 3. You should report all cases with days away from work (with or without job transfer or restriction). If your NAICS code begins with: 238, 311, 444, 481, 493, or 623, you should also report all cases with days of job transfer or restriction (without days away from work). Your NAICS code is located on the mailing label on the front of this booklet. To identify the individual cases to report, follow these steps:


  3. Step 1: Go to your completed OSHA Form 300.
    Note each case that has a check in column (H) and/or Column(I).
    These are the only cases you should report.
    Step 2: Fill out one Injury and Illness Case Form for each case that you identified in Step 1. You can find most of the information on a supplementary document such as the Injury and Illness Incident Report (OSHA Form 301), a workers' compensation report, an accident report, or an insurance form.
    Step 3: If more than one establishment is noted on the front cover under "Report for this Location," be sure to look at all your OSHA Form 300's to find which cases to report.
    Step 4: We have designed this survey to ensure that you do not have to report more than approximately 15 cases. If you have significantly more than 15 cases, please go to Section 5: If You Need Help . . . at the back of this booklet and call the phone number(s) listed for your State for assistance. If you need additional Injury and Illness Case Forms, you may either photocopy a blank form or go to Section 5: If You Need Help . . . at the back of this booklet and call the phone number(s) listed for your State.
    Step 5: When you are finished, proceed to Section 4: Contact Information on the back cover of this booklet and provide information for the person who completed this survey.

Pages 6 and 7 - Injury and Illness Case Form

Tell us about the incident - enter the employee's name, job title, date of injury or onset of illness, number of days away from work and number of days of job transfer or restriction.

Tell us about the employee - check the category which best describes the employee's regular type of job (this is optional), check the employee's race or ethnic background (this is optional), enter employee's age at the time of injury or illness OR the employee's date of birth, enter the length of time the employee has worked at this establishment OR check the employee's length of service and finally, check the employee's gender.

Tell us about the incident - check whether the employee was treated in an emergency room and whether the employee was hospitalized overnight as an in-patient. Enter the time the employee began work on the date of the injury, enter the time the injury occurred or check if the time cannot be determined, check if the injury occurred before, during or after the workshift (this is optional). Describe what the employee was doing just before the incident occurred. Describe how the injury or illness occurred. Describe the part of body affected by the injury and how it was affected and finally, describe the object or substance that directly harmed the employee.

BLS USE ONLY

Page 8 - Section 4

Please let us know who completed the survey in case we need to call with questions.

Page 8 - Section 5

Contact phone numbers and fax numbers are provided for all of the States collecting this survey.

 

Last Modified Date: March 12, 2014