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Download Fax Forms
If there were few or no work-related injuries and illnesses at your sampled establishment in calendar year 2023, 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: December 4, 2023
