Injury and Illness: Recordkeeping

Data Collection Form

For this year's data collection (2012), the ODI survey requests the totals from the selected establishment's 2011 Summary of Work-Related Injuries and Illnesses (OSHA No. 300A), as well as information about hours worked and employment at the establishment. The Occupational Safety and Health Act, 29 U.S.C. §§ 657 & 673, and reporting regulations at 29 C.F.R. Part 1904 authorize OSHA to collect the requested information. All establishments that receive this data collection request should submit data within 30 days, even if they had no work-related injuries or illnesses recorded on their 2011 OSHA No. 300 form.

A sample copy of the data collection form* is available. Only companies that received a request for data in the mail need to complete this form and submit data to OSHA.

OSHA estimates that it will take, on average, 10 minutes to complete this data collection, including the time spent reviewing the instructions, searching and gathering the data needed, and submitting the information. Please note that establishments that fail to submit a completed 2009 survey may be subject to OSHA enforcement actions, including the issuance of a citation and assessment of penalties.

OSHA's preferred method of data submission is electronically via OSHA's data collection web site (Form 196 web site). Establishments that cannot or are unwilling to submit data electronically, may call the collecting state (at the telephone number on the cover of the notification) for a hard copy survey or log into OSHA's web site and print a copy of the survey form. They can then complete the hard copy survey and return it to the collecting state via fax or mail.

OSHA makes every effort to reduce the survey completion time while still obtaining the necessary information. For help submitting data, please call the phone number printed on the survey label.

Thank you for helping us collect accurate information and for participating in the effort to make America's workplaces safer and healthier.

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*This file is provided for downloading only

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