Osha Work-Related Injury And Illness Data Collection Form, 2011 (Page 2 of 4) in pdf

Dear Employer:

The U.S. Department of Labor, Occupational Safety and Health Administration (OSHA) is working with State agencies to compile

work-related injury and illness data from employers within specific industry and employment size specifications. The information

will be used to focus OSHA activities (inspections, outreach, consultations, technical assistance, and leveraging programs) and to

measure the performance of the Agency in meeting its goal of reducing workplace injuries and illnesses.

We are asking for the totals from your 2011 Summary of Work-Related Injuries and Illnesses (OSHA No. 300A), as well as infor-

mation about hours worked and employment at your 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. Please

note that establishments that fail to submit the requested data may be subject to OSHA enforcement actions, including the issuance

of a citation and assessment of penalties.

At this time the Bureau of Labor Statistics (BLS) and its State partners are conducting the 2011 Survey of Occupational Inju-

ries and Illnesses, Part 1 of which solicits information very much like what OSHA is collecting. Be aware that employers who

receive the BLS survey as well as the OSHA data collection form are required by law to respond to both of them, since these

are separate data collection efforts. However, if you have already received the BLS survey, OSHA affords you an option

intended to streamline the effort involved in responding to both collections: That is, you may either (1) complete the

OSHA form in its entirety, in addition to the BLS form, or (2) simply send OSHA a copy of your responses to the BLS

survey (Parts 1A and 1B), which OSHA will accept as your response to the Agency’s collection.

We recognize that responding to our questions may be time consuming for some employers and we have made every effort to reduce

the completion time while still obtaining the necessary information. In this spirit, we now provide multiple means of submitting

your data: (1) Submit your data electronically via OSHA’s website at (2) Complete

this PDF form,* and submit it electronically by selecting the Submit Form button at the bottom of page 4 (in the Sign and Return

This Form section). (3) Complete this PDF form* and fax or mail a copy to the collecting agency noted on the front cover. If you need

help in completing the survey form or if you have questions, please call the phone number printed on the cover.

OSHA has initiated a comprehensive approach to monitoring and improving data quality. As part of this approach, OSHA will

audit the injury and illness records of a randomly chosen sample of establishments included in this data collection. We will continue

to evaluate this initiative and will build on the lessons learned to improve OSHA’s ability to protect the health and safety of Amer-

ica’s workers sensibly and appropriately. We invite your comments as we proceed with this effort. Thank you for helping us collect

accurate information and for participating in the effort to make America’s workplaces safer and healthier.

Occupational Safety and Health Administration

U.S. Department of Labor

Who must complete this form?

All establishments that receive this form should complete and return it via email or respond via the Internet within 30 days, even if

they had no work-related injuries and illnesses recorded on their 2011 OSHA Form No. 300.

What else do you need?

Information from your 2011 Summary of Work-Related Injuries and Illnesses (OSHA No. 300A).

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What do you need to do?

Complete this form only for the establishment requested (see the label of the original request for data you received in the mail).

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Complete pages 3 and 4 by entering the data from your OSHA Form 300A into this fillable PDF form.

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On the last page, fill in the name, telephone, fax, and email address of the person we should contact with questions.

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Submit the data to OSHA within 30 days of receipt of the original request for data by selecting the Submit Form button

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at the bottom of page 4 (in the Sign and Return This Form section).

*To complete the form, Adobe Acrobat Reader software is required. To download the latest version, visit

Osha Work-Related Injury And Illness Data Collection Form, 2011 Page 2

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