1. Purpose.
   
   
2. Scope.
   
   
3. Significant Changes
   
   
4. References.
   
   
5. Cancellation.
   
   
6. Expiration Date.
   
   
7. Federal Program Change.
   
   
8. Action.
   
   
   1. Responsible office
   2. Action offices
   3. Information offices
9. Background.
   
   
10. General Procedures.
    1. Scope
    2. Inspection procedures
    3. Audit components
    4. Formal training of personnel
    5. Employee participation
    6. Opening conference
    7. Closing conference
       
       
11. Procedures to Conduct Data Check and Records Audit.
    
    
    1. Determine the availability and location of records
    2. Obtain a copy of the employer's completed OSHA 300 Log
    3. Compare the Log Summary and the hours worked data
    4. Determine the audit sample size
    5. Review all pertinent records
    6. Review employer's Log
    7. Interview the Designated Recordkeeper(s)
    8. Conduct Employee Interviews (optional)
    9. Determine audit results
       
       
12. Issuance of Citations.
    
    
13. Evaluation.
    
    
14. Recording and Tracking
    
    

1. Purpose. This Instruction establishes a program and the procedures to be used to conduct audits to verify the accuracy of the data employers submit as part of the OSHA Data Initiative (ODI) and the accuracy of the underlying data on which the employer's ODI submission is based.
   
   
2. Scope. OSHA-wide. The Audit and Verification program will be conducted by Federal Area Offices or, by agreement with a State, by State personnel.
   
   
3. Significant Changes. The document has been changed from a OSHA Notice to an OSHA Instruction due to the ongoing nature of the program The protocol for conducting the audits is unchanged. The reference year of the documents to be audited will be communicated to the field through a memorandum.
   
   
4. References.
   
   
   1. OSHA Instruction CPL 02-00-103 (CPL 2.103), Field Inspection Reference Manual (FIRM), September 26, 1994.
      
      
   2. OSHA Instruction CPL 02-00-131 (CPL 2-0.131), Recordkeeping Policies and Procedures Manual, January 1, 2002.
      
      
   3. OSHA Instruction CPL 02-02-046 (CPL2-2.46), Authorization and Procedures for Reviewing Medical Records, January 5, 1989.
      
      
   4. CFR 1913.10(b)(6), Authorization and Procedures for Reviewing Medical Records.
      
      
   5. OSHA Instruction ADM 03-01-005 (ADM 12.5A), OSHA Compliance Records, June 28, 1993.
      
      
   6. OSHA Instruction ADM 01-00-002 (ADM 4.4), Administrative Subpoenas, August 19, 1991.
      
      
   7. OSHA Instruction CPL 02-00-080 (CPL 2.80), Handling of Cases To Be Proposed for Violation By Violation Penalties, October 21, 1990.
      
      
   8. FIRM change memorandum: Mandatory Collection of OSHA 200 and Lost Workday Injury and Illness (LWDII) Data During Inspections, June 21, 1996.
      
      
      
      
5. Cancellation. OSHA Notice 05-01 (CPL 02) Audit and Verification Program of 2003 Occupational Injury and Illness Records, January 21, 2005.
   
   
6. Expiration Date. None.
   
   
7. Federal Program Change. The OSHA Data Initiative (ODI) is a Federal program in which some State Plan States participate by collecting data under a cooperative agreement with OSHA. States that utilize the data to target their activities and for performance measurement, etc., have an interest in the quality of the data and are encouraged to participate in the audit program. (States that decline to participate in the audit program may choose to have Federal OSHA conduct audits in their State or may request that audits not be performed in their State.) States may conduct the audits with either compliance or non-compliance staff, as long as the personnel who conduct the audits are authorized to obtain access to employee medical records. States that have opted to participate in the Audit and Verification Program should follow the guidelines in this document, with the exception of section XII concerning citations. Although State Plan States have the legal authority and may take enforcement action concerning recordkeeping violations found during audits under the State equivalent of 29 CFR Part 1904.41, they may also develop alternate procedures for handling recordkeeping violations discovered during the audits.
   
   
8. Action. The Regional Administrators and Area Directors shall ensure that the procedures established in this Instruction are adhered to in Federal enforcement jurisdictions.
   
   
   1. Responsible Office. Office of Statistical Analysis (OSA), Directorate of Evaluation and Analysis.
      
      
   2. Action Offices. National, Regional and Area Offices, State Plan States.
      
      
   3. Information Offices. Directorate of Cooperative and State Programs; Office of Occupational Medicine, Directorate of Science, Technology and Medicine.
      
      
9. Background. OSHA has developed and implemented a system to collect and compile data on occupational injuries and illnesses for individual establishments in certain private sector industries. These data, combined with other data, will be used for OSHA's enforcement and compliance assistance programs, and to assess the results of the Agency's efforts to improve safety and health in the nation's workplaces.
   
   Quality assurance is an integral part of the data collection process to ensure that the data OSHA collects accurately reflect the injury and illness experience at the workplace. As a condition of the OMB clearance for the data collection, OSHA must evaluate the accuracy of data that employers submit, assess the effect(s) of the data collection on employer recordkeeping practices, and estimate the extent of employer compliance with OSHA's recordkeeping requirements.
   
   On-site audit of employer records is the best method to verify the accuracy of employer-maintained data on occupational injuries and illnesses. OSHA developed methods intended to facilitate the use of the audit procedures, such as statistical sampling of employees within an establishment for review of their records and computer software to help conduct and document the audit.
   
   
10. General Procedures.
    
    
    1. Scope. OSHA, or State personnel in States that have agreed to participate in the Audit and Verification Program, will conduct a data check and records audit on a sample of 250 establishments selected by OSA using a random sampling protocol developed for the project. The sample will be chosen from the universe of general industry establishments within the scope of the OSHA Data Initiative (approximately 125,000 establishments).
       
       An establishment will not be audited if it meets any of the following criteria: (1) The establishment had fewer than 40 total employees during the reference calendar year; (2) The establishment was not in one of the SICs listed in Appendix D; (3) The establishment is a corporate office location with no production facilities; or (4) The establishment was not required to maintain an OSHA Log during the reference calendar year. Furthermore, if an establishment is an approved participant in OSHA's Voluntary Protection Programs (VPP), or in the OSHA Consultation's Safety and Health Achievement Recognition Program (SHARP), or is participating in an OSHA Strategic Partnership, it is to be deleted from the inspection list. If it is determined that an assigned establishment meets any of these criteria, the audit should not be performed. Contact the Office of Statistical Analysis and a replacement establishment will be provided.
       
       
    2. Inspection Procedures. For audits conducted in Federal jurisdiction, normal inspection procedures as established in the Field Inspection Reference Manual (FIRM) CPL 02-00-103 (CPL 2.103) will be followed, including the opening conference (to include determination if an OSHA-funded consultation is in progress or whether the facility is pursuing or has received an inspection exemption status (29 CFR 1908.7(b)(1) and the Consultation Policy and Procedures Manual, Chapter 7), records verification, employee interviews, and closing conference, with the exception that walkaround inspections will not normally be performed unless a complaint is received or the Area Director has approved the expansion of the site visit. If any complaints are made to the CSHO that are not related to recordkeeping, the CSHO will, at his or her discretion, address the complaint or refer the complaint to the Area Office for processing. Furthermore, if through review of the injury and illness records the CSHO perceives a significant safety or health hazard (e.g., amputations associated with a specific work process), the CSHO should contact the Area Director to obtain approval to expand the site visit to address the significant safety or health hazard.
       
       Each data check and records audit visit will be counted as an OSHA inspection requiring the completion of an OSHA-1. Pre-inspection planning will consist primarily of a general familiarization with the size and activity of the establishment to be inspected, a check for VPP or SHARP status, and the entry of preliminary data into the associated software, OSHA Recordkeeping Audit Assistant (ORAA). For audits conducted in Federal jurisdiction, a Medical Access Order (MAO) is required to review medical information with personal identifiers. MAOs for each employer (and/or the employer's designated health care provider or medical records holder) should be requested from the OSHA Medical Records Officer (MRO). The MRO is located in the Office of Occupational Medicine (OOM), Directorate of Science, Technology and Medicine, and is responsible for ensuring that all medical records are protected under guidelines as mandated in 29 CFR 1913.10. OSA will supply the MRO with an advance listing of establishments to be inspected under the Audit program. However, each Area Office will be responsible for contacting OOM, either through fax or the web request site, and providing written detailed information on each inspection (i.e., purpose, employer, date(s) of inspection, and the name(s) and address(es) of the individual(s) conducting the inspection (see Appendix B for a sample MAO request form). In addition, if the scope of the inspection is expanded and requires review of additional medical records, the CSHO must consult with OOM in order to determine whether the MAO requires an amendment or additional documentation. Case files shall be established in accordance with ADM 03-01-005 (ADM 12.5A).
       
       
    3. Audit Components. As detailed in Section XI, Procedures to Conduct Data Check and Records Audit, the data check and records audit shall involve:
       
       
       1. Comparing the employer's Log Summary, employment and hours worked data submitted to OSHA for the data collection with the Log Summary, employment and hours worked data provided at the establishment (OSHA Form 300A);
          
          
       2. Selecting a sample of employees within the establishment;
          
          
       3. Reviewing available documentation concerning any injuries or illnesses for each employee selected in the sample to identify recordable cases;
          
          
       4. Comparing recordable cases discovered from the files of selected employees with the establishment's OSHA Form 300 (Log) to determine if the employer properly recorded cases on the Log and to identify recordable injuries and illnesses that the employer did not record (under-recording);
          
          
       5. Scanning the establishment's Log to identify cases entered on the Log involving the selected employees that were not recordable (over-recording);
          
          
       6. Interviewing the establishment's recordkeeper(s) about OSHA recordkeeping requirements and their establishment's recordkeeping practices;
          
          
       7. Using the OSHA Recordkeeping Audit Assistant (ORAA) software system to record information gathered during the audit as described in Appendix A, "Steps for Conducting the Data Check and Records Audit Using the OSHA Recordkeeping Audit Assistant (ORAA) Software."
          
          
    4. Formal Training of Personnel. OSA will conduct one or more two-day training session(s) for OSHA and State personnel new to the program. The specialized training will address: the procedures for comparing the collected data with the employer's Log and for conducting the audit to verify the accuracy of records; the method for selecting a sample of employees within the establishment; the use of the OSHA Recordkeeping Audit Assistant (ORAA) software system for documenting and tracking audit information; and a review of CPL 02-02-046 (CPL 2-2.46), "Authorization and Procedures for Reviewing Medical Records."
       
       
    5. Employee Participation. As called for in this directive, some employees must be interviewed during each audit. Procedures in section A.4.e. of Chapter II of the FIRM CPL 02-00-103 (CPL 2.103) will be followed for all interviews.
       
       Whenever the scope of the inspection is expanded beyond the audit, CSHOs shall involve employee representatives in the walkaround as outlined in Section A.2.h of Chapter II of the FIRM CPL 02-00-103 (CPL 2.103) in accordance with normal inspection procedures.
       
       Whenever the CSHO believes that the injury and illness records reviewed did not provide full and accurate information pertaining to injuries and illnesses experienced by the employees, the CSHO shall use the procedures outlined in section XI. H of this directive to select a sample of employees to interview.
       
       
    6. Opening Conference. The CSHO shall present an explanatory letter (Appendix B) to the employer explaining the purpose, scope, and process for the data check and records audit. In addition, the CSHO will provide the employer with at least two copies of a Medical Access Order attached to a cover letter which addresses the medical records review concerns. For audits conducted in Federal jurisdiction, the CSHO shall also inform the employer about the Agency citation policy (Section XII below) and indicate that where applicable, violations will be cited accordingly. The employer and employees shall be informed that any complaints received that are not related to recordkeeping will be addressed by the CSHO at his or her discretion or referred to the Area Office for processing.
       
       
    7. Closing Conference. At the conclusion of the records audit, the CSHO shall conduct a closing conference with the employer and the employee representatives. The CSHO shall discuss the strengths and weaknesses of the employer's recordkeeping program, and describe any recordkeeping deficiencies and violations found during the data check and records audit. For audits conducted in Federal jurisdiction, the closing conference shall follow the procedures established in the FIRM CPL 02-00-103 (CPL 2.103) as applicable to these inspections.
       
       
11. Procedures to Conduct Data Check and Records Audit. The procedures described in this section and the referenced Appendices are included to ensure consistency in implementation of the program, and to support a meaningful evaluation of the results.
    
    
    1. Determine the availability and location of records needed to conduct the audit (the employer's OSHA Log, employee roster, medical records, etc.).
       
       The availability of records required for the audit and their location at the establishment are to be recorded on a checklist in ORAA. (A hard copy is included in Appendix C, "Records Identification Worksheet".)
       
       
    2. Obtain a copy of the employer's completed OSHA Form 300 for the establishment for the reference calendar year; the total hours worked for all employees and the average number of employees for the reference year; and a copy of a complete roster of all employees who worked at the establishment during the reference year.
       
       The employee roster should include full-time, part-time and seasonal employees. The listing may be an alphabetic listing, a payroll listing, a listing by department, or it may be in some other form. The roster must be for employees who worked during the reference calendar year. The list should not contain multiple entries for an individual.
       
       Ask the employer for the total hours worked and the average number of employees at the establishment for the reference year. These figures should be available from the employer's completed OSHA Form 300A. If, however, the numbers are not available, the values can be estimated using the worksheet on the back of the OSHA Form 300A.
       
       Note: The average employment figure will almost always be less than the total number of employees on the employee roster due to employee turnover.
       
       
    3. Compare the Log Summary and the hours worked data submitted to OSHA for the data collection with the data provided at the establishment.
       
       The Submission Comparison Worksheet section of ORAA (hard copy contained in Appendix C) shall be used to compare the Log Summary and hours worked data submitted for the Data Initiative collection with the data provided by the employer at the establishment. The data submitted by employers in response to the ODI collection, including the name of the person who signed the data collection form, will be pre-entered into the worksheet for the CSHO. The CSHO shall enter the employment and injury and illness values from the establishment's OSHA Form 300A that is provided to the CSHO at the establishment. The values should be entered exactly as recorded by the employer. Adjustments or corrections should not be made by the CSHO. The calculation of the percentage difference is performed by ORAA. If there are differences in the numbers of cases reported and/or the number of hours worked, the CSHO shall ask the person who signed the submission why the numbers differ. If this person is not available, the question should be addressed to the recordkeeper or the manager. The response should be recorded on the Worksheet.
       
       
    4. Determine the audit sample size and draw sample of employees.
       
       The first step is to ascertain the total number of employees on the reference year employee roster and the total number of cases recorded on the OSHA Form 300. When these parameters are entered into the ORAA function section "Determine Audit Sample", the software will provide the number of employees whose records will be reviewed in the audit, the random starting point and the sampling period.
       
       The CSHO shall use the reference year employee roster to select the employees whose records will be reviewed (employees are not sampled from the Log). Counting down from the top of the roster, the first employee selected is determined by the "random starting point" supplied by ORAA. Continue counting down the value of the "sampling period" and note each employee selected until the sample size is obtained. For example, if the random starting point is 10, the 10th employee listed on the roster is the first selection and if the "sampling period" is 18, every eighteenth employee after the first is selected until the sample size is achieved (note: the required sample may be achieved before the end of the roster is reached).
       
       If in identifying the sample of employees the CSHO determines that an employee name is a duplicate or cannot be used for whatever reason, he/she shall substitute the next employee name on the roster. If the CSHO comes to the end of the employee roster before obtaining the required sample size, he/she shall continue the interval count from the top of the employee roster.
       
       The CSHO shall compile a list of the employees selected for the audit sample.
       
       
    5. Review all pertinent records for each employee selected in the audit sample and independently reconstruct log entries for the sampled employees. Compare the reconstructed cases with the employer's OSHA Form 300.
       
       The CSHO shall perform a comprehensive review of the sampled employees' records in order to identify all of the occupational injuries and illnesses that may have occurred to those employees for the reference year. The records to be reviewed shall include medical records, workers' compensation records, insurance records, and if available, payroll/absentee records, company safety incident reports, company first aid logs, and/or alternate duty rosters.
       
       For audits conducted in Federal jurisdiction, the CSHO shall conduct the review of medical records in accordance with the procedures as specified in CPL 02-02-046 (CPL 2-2.46) and in 29 CFR 1913.10(b)(6), "Authorization and Procedures for Reviewing Medical Records."
       
       Using the various records compiled, the CSHO shall independently construct Log entries for the recordable cases identified from the employee files. The CSHO shall identify the recordable cases and enter the reasons for recordability into the ORAA. (Note: An exact calculation of days away from work and days of restricted work activity is not required. An approximation based on an initial review of the records is acceptable.) The CSHO shall then use the ORAA software to compare the reconstructed Log entries with the employer's Form 300 Log, and to document any differences that exist.
       
       The CSHO shall make copies of the OSHA Form 300 for inclusion in the case file. For audits conducted in Federal jurisdiction the CSHO shall also make copies of any documentation needed to support discovered recordkeeping deficiencies. If a copying machine is not available, or is not made available for CSHO use, or if the employer will not allow appropriate documents to be temporarily removed from the premises, the CSHO shall subpoena all records considered necessary for verification using the procedures outlined in the FIRM 02-00-103 (CPL 2.103) Chapter II. Section A.2.c.(3) and ADM 01-00-002 (ADM 4.4).
       
       
    6. Review employer's log to identify any cases recorded for the sampled employees that do not meet the OSHA recordability criteria (over-recording).
       
       After reviewing the sampled employees' files, the CSHO shall scan the employer's Log for any recorded cases for the sampled employees not identified as recordable in the file review. The CSHO will determine the cases' recordability by considering the documentation in the employee's records and, if necessary, talking with the employer, recordkeeper or employee. The CSHO shall document any over-recorded cases in ORAA. Documentation of over-recorded cases should be limited to cases pertaining to the sampled employees only.
       
       
    7. Interview the Designated Recordkeeper(s).
       
       The CSHO shall interview the designated recordkeeper(s) (a maximum of two persons) regarding the manner in which injuries and illnesses are recorded at the establishment. The purpose of this interview is to assess each recordkeeper's knowledge of the OSHA injury/illness recordkeeping requirements and to determine whether recordkeeping problems exist. The CSHO shall use the Recordkeeping Procedures Questionnaire, and should enter responses into ORAA. (A hard copy is included in Appendix C.)
       
       If the CSHO learns of any company policies that may have an effect on the injury and illness records, these should be noted in the comments section of the questionnaire. For example, if the CSHO learns that there is an awards program tied to the number of injuries and illnesses recorded on the OSHA Log, the program is to be described in the comments section.
       
       
    8. Conduct Employee Interviews.
       
       Employee interviews must be conducted using the following procedures if the CSHO believes the injury and illness records reviewed did not provide full and accurate information pertaining to injuries and illnesses experienced by the employees. A sub-sample of employees to be interviewed must be selected from the list of employees selected for the audit sample in section XI.D, above. The suggested number of employees to be interviewed is contained in the Employee Questionnaire function of ORAA. The questionnaire to be used in the interview is the Employee Questionnaire. Responses to the questionnaire are entered into ORAA. (A hard copy is included in Appendix C.)
       
       
    9. Determine audit results.
       
       Upon completion of the audit, the CSHO shall use ORAA to generate a summary of the audit findings, including the percentages of cases over-recorded and under-recorded. This summary can be used in the closing conference in discussing the audit findings with the employer and should be included in the case file as part of the audit documentation.
       
       
12. Issuance of Citations. Whenever OSHA recordkeeping violations are identified by Federal personnel conducting audits within their Federal enforcement authority, appropriate citations and penalties shall be proposed and supporting documentation shall be provided in accordance with guidelines in the FIRM CPL 02-00-103 (CPL 2.103) and CPL 02-00-131 (CPL 2-0.131).
    
    
    1. Recordkeeping violations found on the OSHA Form 300. Chapter 2, Paragraph II.A of CPL 02-00-103 (CPL 2.131) states "All CSHOs on all inspections must review and record the establishment's injury and illness records for the three prior calendar years..." If, during this review, the CSHO identifies recordkeeping violations on the OSHA Form 300, the CSHO will issue citations in accordance with CPL 02-00-103 (CPL 2.131), Chapter 2, Paragraph II.B.
       
       
    2. Citations for violations found shall be classified as other-than-serious with proposed penalties appropriate to the circumstances in each case. If violations are characterized as "willful," "repeat," or "failure to abate," the Regional Administrator or Regional Solicitor should be contacted for guidance.
       
       
    3. Violation-by-violation citation and penalty procedures shall be considered, if appropriate, in accordance with OSHA Instruction CPL 02-00-080 (CPL 2.80) and the FIRM CPL 02-00-103 (CPL 2.103).
       
       
    4. Employers shall not be cited for over-reporting of cases. The employer shall be informed of such over-reporting and the need to eliminate these identified cases on the employer's OSHA Form 300 Log.
       
       
    5. The primary purpose of the Audit and Verification Program is to assure the statistical accuracy of the data collected under the ODI and employers generally will not be cited for violation of 1904.41 (failure to submit data to OSHA) or for discrepancies found during the audit in their Data Initiative submission compared to the establishment's OSHA Form 300, employment and hours worked data as part of the audit inspection.
       
       
    6. When OSHA recordkeeping violations are identified by Federal personnel conducting audits of employers within the State's authority to enforce, and they are unaccompanied by State personnel, such apparent violations should be referred to the appropriate State plan.
       
       
    7. When OSHA recordkeeping violations are identified by State personnel conducting audits or accompanying a Federal auditor in their State, the State's procedures developed in accordance with section VII of this document regarding the handling of such violations should be followed.
       
       
    8. Other violations shall be cited, as appropriate, for a limited scope inspection.
       
       
13. Evaluation. The Area Director will provide OSA with an ORAA data file of the audits. The file can be submitted by e-mail.
    
    In a final report, OSA will summarize the findings of the audit project, including (but not limited to) the accuracy of the data that employers submitted to OSHA for the data collection, employer knowledge about OSHA injury/illness recordkeeping requirements, and the level of compliance with 29 CFR Part 1904.
    
    
14. Recording and Tracking. In accordance with the FIRM CPL 02-00-103 (CPL 2.103) change memorandum: "Mandatory Collection of OSHA 200 and Lost Workday Injury and Illness (LWDII) Data During Inspections" issued by a Deputy Assistant Secretary Memorandum to the Regional Administrators dated June 21, 1996, the CSHO shall enter the summary line of the employer's Form 300 Logs and the hours worked for three prior calendar years into the IMIS.
    
    OSHA-1 item "inspection type" should be coded as "Planned -- Other." OSHA-1 item "scope" should be coded as "Partial Inspection" and classify the inspection as "Records only". To facilitate tracking of these inspections for evaluation of the program, an IMIS code of "RKAUDIT" will be entered in the Optional Information block of the OSHA-1.

    Type	ID	Value
    N	16	RKAUDIT

1. Your [enter reference year] employee roster(s) (The roster is to include labor, executive, hourly, salary, part-time, and seasonal workers. Also, if available, provide a list of temporary help services workers that your firm directly supervised during the reference year.)
2. Your [enter reference year] OSHA Form 300 and Form 300A
3. Workers' Compensation First Reports of Injury for a sample of employees
4. Medical records for a sample of employees (To protect the privacy of medical records, a formal written Medical Access Order is attached. It explains this process more fully.)
5. The total number of hours worked by your employees in [enter reference year]
6. The average number of persons you employed in [enter reference year]

• Submission Comparison Worksheet
  
  
• Records Identification Worksheet
  
  
• Recordkeeping Procedures Questionnaire
  
  
• Employee Interview Questionnaire (Optional)
  

A) Differences in hours worked:

B) Differences in the number of recorded cases:

C) Other differences (e.g., average number of employees, number of days away from work, etc.):

(Name)	Last:                 First:                Middle:

Title:

Date:

[ ]     a.     The OSHA Regulation 29 CFR Part 1904
[ ]     b.     Instructions on the OSHA forms
[ ]     c.     OSHA website
[ ]     d.     Internal guidelines
[ ]     e.     Other (list)

[ ]     Yes         [ ]     No

[ ]     Yes         [ ]     No

[ ]     Yes         [ ]     No

[ ]     Yes         [ ]     No

[ ]     Yes         [ ]     No

(1)     [ ]     OSHA Form 301
(2)     [ ]     State Workers' Compensation Form
(3)     [ ]     Insurer's Form
(4)     [ ]     Other

[ ]     Yes         [ ]     No

b.     If not, who is? ________________________

[ ]     Self taught/no formal training
[ ]     Trained by supervisor, colleague, or previous recordkeeper
[ ]     Classroom training
[ ]     Other (please specify)_______________________________________

[ ]     Frequently         [ ]     Occasionally         [ ]     Never

• All injuries are recordable     [ ]     Yes         [ ]     No
• Visit to doctor for observation only     [ ]     Yes         [ ]     No
• First aid     [ ]     Yes         [ ]     No
• Medical treatment     [ ]     Yes         [ ]     No
• Loss of consciousness     [ ]     Yes         [ ]     No
• Restricted work activity     [ ]     Yes         [ ]     No
• Days away from work     [ ]     Yes         [ ]     No

• All illnesses are recordable
      [ ]     Yes         [ ]     No
• Illnesses are recordable only when they meet the same criteria for recording injuries
      [ ]     Yes         [ ]     No

• All potentially contaminated needlesticks are recordable
      [ ]     Yes         [ ]     No
• A case of occupational hearing loss is recordable only if there is a shift of 25dB or greater
      [ ]     Yes         [ ]     No

• Only if it occurred while the employee was on the clock     [ ]     Yes         [ ]     No
• Workers' Compensation decides     [ ]     Yes         [ ]     No
• Employee tripped in parking lot     [ ]     Yes         [ ]     No
• It is caused by work     [ ]     Yes         [ ]     No
• It is contributed to by work     [ ]     Yes         [ ]     No
• Employee injured during commute     [ ]     Yes         [ ]     No

• Cannot work full shift     [ ]     Yes         [ ]     No
• Cannot perform a job task employee regularly does once a week     [ ]     Yes         [ ]     No
• Cannot perform a job task employee regularly does once a month     [ ]     Yes         [ ]     No
• Doctor's note with restrictions that does not affect the employee's ability to perform all duties
      [ ]     Yes         [ ]     No

Last:                 First:                 Middle:

Date:                 Occupation (regular job title):

Tenure (length of time on the job):

Department/Division:

1. a. Have you ever seen an OSHA Form 200 or Form 300, the Log of Occupational Injuries and Illnesses, for your establishment?
   [ ] Yes         [ ] No
   
   b. If yes, did you see it by:
   [ ] Viewing the summary portion of the log posted by the employer.
   [ ] Requesting access to see the entire OSHA Log.
   
   
2. Did you experience an injury or illness during CY _____ that was caused or aggravated by an event or exposure in your work environment?
   [ ]     Yes (go to Question 3)         [ ]     No (go to Question 7)
   
   
3. Briefly describe this injury and/or illness.
   
   
   
   
4. a. Did you report the injury or illness to your employer?
       [ ]     Yes         [ ]     No
   
   b. If yes, was the case recorded on the OSHA Log?
   [ ]     Yes         [ ]     No         [ ]     Don't Know
   
   c. If no, why not?
   
   
   
   
5. Have you or your employer filed for workers' compensation for this injury or illness?
       [ ]     Yes         [ ]     No
   
   
6. a. Did your injury and/or illness involve any days away from work or days of restricted work activity? If yes, explain.
       [ ]     Yes         [ ]     No
   
   b. If yes, how many workdays?
           _____ Number of days away from work
           _____ Number of days restricted work activity
   
   
7. a. Are you aware of any of your coworkers experiencing a job-related injury or illness during CY 2004?
       [ ]     Yes         [ ]     No
   
   b. If yes, who?