Instructions

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Front Page		Label		Page 2		Page 3
Page 4		Page 5		Page 6 - 11		Page 12

 

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

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.)

The address presented in the upper right of the label appears through the window of the Business Reply Mail envelope when you return the survey to us.

The location(s) for which the survey should be completed are listed under 'Report for this Location:' in the bottom left of the label. Also presented here is a phone number you can call for assistance, your account number and temporary password for on-line completion of the survey. The remaining items in this portion of the label are for survey use only.

Your establishment ID (needed for on-line collection or e-mail collection of your data) is presented in the bottom right of the label. Your company address is also presented here.

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 this Location." If you are unsure, please call the number listed on the front of this form as "For Help Call:." If you had no work-related injuries and illnesses in 2007, answer all questions in Section 1 of the survey. If you had at least one work-related injury or illness in 2007, answer all questions in Sections 1 and 2 of the survey. For any work-related injuries or illnesses with days away from work which occurred in 2007, also complete Section 3.
Step 2:	Check "Your Company Address" 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 2006.
Step 4:	Write the name of the person who completed this survey in case we have questions in Section 4: Contact Information on the back cover 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. Alternative methods of reporting, such as e-mail or the Internet, are explained in a brochure in the middle of this booklet.

Page 3 - Section 1

Enter your account number in item 1. Your account number is printed on the front of your form.
Enter your annual average number of employees during 2007 in item 2.
Enter your total hours worked by all employees during 2007 in item 3.
Check any unusual circumstances that might have occurred during 2007 to affect your answers in items 2 or 3. For example, your number of employees grew during 2007 because of grown or the number of hours worked by your employees fell during 2007 because of a strike.
Check whether your establishment experienced any work-related injuries or illnesses during 2007 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 2007 and to estimate your total hours worked for 2007 are presented on page 4.

Page 5

1. If you had NO cases with days away from work in Column H, you are finished with the survey.
   Go to Section 4: Contact Information on the back cover of this booklet and provide information for the person who completed this survey.
2. If you had cases with days away from work in Column H, please complete this Section 3.
3. You should only report cases with days away from work. To identify the individual cases to report, follow these steps:

Step 1:	Go to your completed OSHA Form 300. Note each case that has a check in column (H). These are the only cases you should report.
Step 2:	Fill out one Case with Days Away from Work 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 listed for your State for assistance. If you need more Case with Days Away from Work 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 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 through 11 - Case with Days Away from Work

Tell us about the case - 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 - 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. 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 12 - Section 4

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

Page 12 - Section 5

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

 

Last Modified Date: July 1, 2008