Osha Work-Related Injury And Illness Data Collection Form, 2011
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OSHA WORK-RELATED INJURY AND
ILLNESS DATA COLLECTION FORM, 2011
OMB No. 1218-0209
U.S. Department of Labor
Approval Expires 4/30/2013
OSHA Form 196B
Occupational Safety and Health Administration
(1/2011)
Options to Report Your Data
Public Law 91-596
requires you to
participate in the data
1.
Submit your data electronically via OSHA’s website at
initiative collection.
.
2.
Complete this PDF form* and submit electronically by selecting the Submit
OSHA estimates that it
Form button at the bottom of page 4 (in the Sign and Return This Form section).
will take you, on average,
10 minutes to complete
Prior to submission, select the Save Form button to save your input to the PDF
the forms in this data
on your computer.
collection, including the
3.
Complete this PDF form, print a copy by selecting the Print Form button at the
time you’ll spend reviewing
bottom of page 4, and fax or mail it to the collecting agency indicated on the
the instructions, searching
label of the original request for data you received in the mail. Remember to
and gathering the data
select the Save Form button to save your input to the PDF to your computer.
needed, and completing and
If you have questions regarding this data collection, please contact the
reviewing the collection of
collecting agency listed on the front cover of the hard copy request for data you
information. Persons are
received in the mail.
not required to respond to
the collection of information
*To complete the form, Adobe Acrobat Reader software is required. To download the latest version, visit
unless it displays a currently
.
valid OMB control number.
If you have any comments
Password: _______________________
ID Number: _______________________
regarding these estimates or
any other aspects of this data
SIC: _____________________
NAICS: _____________________
collection, send them to:
Company Mailing Address:
U.S. Department of Labor
Occupational Safety and
CONTACT:
_______________________________________________________________________
Health Administration
(FirstName LastName)
Directorate of Evaluation
TITLE: _______________________________________________________________________
and Analysis
Office of Statistical Analysis
PHONE, ex. 1234567890:
______________________________________ EXT: __________________________
Room N-3644
COMPANY: _______________________________________________________________________
200 Constitution Ave. N.W.
Washington, D.C. 20210
SECONDARY NAME: _______________________________________________________________________
ADDRESS: _______________________________________________________________________
_______________________________________________________________________
CITY/STATE/ZIP: __________________________________________________ _______ __________
Reporting Site Address:
ADDRESS: _______________________________________________________________________
_______________________________________________________________________
CITY/STATE/ZIP: __________________________________________________ _______ __________
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