Attachment 2 196b2007-surveyform.pdf

OSHA WORK-RELATED INJURY AND

ILLNESS DATA COLLECTION FORM, 2007

Public Law 91-596 requires you to participate in the data initiative collection.

OSHA estimates that it will take you, on average, 10 minutes to complete the forms in this data collection, including the time you’ll spend reviewing the instructions, searching and gathering the data needed, and completing and reviewing the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number.

If you have any comments regarding these estimates or any other aspects of this data collection, send them to:

U.S. Department of Labor Occupational Safety an Health Administration Directorate of Evaluation and Analysis Offi ce of Statistical Analysis Room N-3644 200 Constitution Ave. N.W.

Washington, D.C. 20210

DO NOT SEND THE

COMPLETED FORM

TO THIS ADDRESS.

Send the completed form to the Return Address indicated on the mailing label.

OMB No. 1218-0209 Approval Expires 3/31/2010

OSHA Form 196B (1/2008)

Please Make Any Necessary Corrections to your Establishment Site Address, SIC, and NAICS.

Place Label Here

U.S. Department of Labor Occupational Safety and Health Administration

Did you know you can submit your form electronically on the web?

Access our electronic survey at http://www.osha.gov/form196/cy07.htm

196b2007-surveyform.indd 1 2/21/2008 12:23:06 PM

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 specifi c industry and employment size specifi cations. 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 2007 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 a completed 2007 survey 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 collecting the 2007 Survey of Occupational Injuries and Illnesses, Part 1 of which solicits information similar to that OSHA is collecting. BLS has compared its survey sample with the OSHA establishment list to identify fi rms selected for both programs. For the convenience of employers identifi ed as being in both programs, the BLS survey and the OSHA data request have been mailed together in the same envelope. Some employers, however, may not have been identifi ed as being in both programs and, thus, will receive the BLS survey and the OSHA request separately.

If you have already received the BLS survey, you may (at your option) either (1) complete this form, or (2) send us a copy of your responses to the BLS survey (Parts 1A and 1B).

We recognize that responding to our questions may be time consuming for some employers and have made every effort to reduce the completion time while still obtaining the necessary information. In this spirit, we now provide two means of submitting your establishment information: (1) by mail or fax, using this hard-copy form, or (2) via the Internet, using a secure electronic version of this form available on our Web site. Instructions for use of the electronic form are displayed at the Web site. You can access an electronic survey form by pointing your browser to http://www.osha.gov/form196/cy07.htm and then, when prompted, inputting your establishment-specifi c ID number and password (provided in the label on the cover of this form). If you choose this option, use your browser’s print function to print a copy for your records. If you need help in completing the enclosed 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 America’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 or respond via Internet within 30 days, even if they had no work-related injuries and illnesses recorded on their 2007 OSHA No. 300.

What else do you need?

� Information from your 2007 Summary of Work-Related Injuries and Illnesses (OSHA No. 300A).

What do you need to do?

� Check the address information printed on the cover. Make any corrections necessary on the hardcopy or Web site.

� Complete this form only for the establishment noted on the cover.

� Complete pages 3 and 4. You can either photocopy your OSHA Form 300A or you can transcribe the entries from your OSHA Form 300A to this survey form.

� On the last page, fi ll in the name of the person we should call with questions and sign the form.

� Return this form in the enclosed envelope, fax, or respond via Internet within 30 days of the date your establishment received it.

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Establishment Information Using your completed Calendar Year 2007 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A), copy the establish-ment information into the boxes below. If these numbers are not available on your OSHA Form 300A, or if your establishment does not keep records needed to answer (1) and (2) below, you can estimate using the steps that follow.

1. For the reporting site identifi ed on the cover: Enter the annual average employment for 2007. (You can copy this from your OSHA Form 300A.)

Annual average number of employees for 2007

If needed: Steps to estimate employment

STEP 1: Add the number of employees your establish-ment paid in every pay period during 2007. Include all employees: full-time, part-time, temporary, seasonal, salaried, and hourly.

Acme Construction pays its employees 26 times each year.

During 2007, In this pay period Acme paid this many employees

830 (sum)

STEP 2: Divide the sum by the number of pay periods your establishment had in 2007. Include any pay peri-ods when you had no employees.

Because Acme has 26 pay periods, it would divide its sum by 26.

830 divided by 26 = 31.92

STEP 3: Round the answer to the next highest whole number. Write the rounded number in the box marked Annual average number of employees.

Acme would round 31.92 to 32 and write that number in the box marked Annual average number of employees.

2. For the reporting site identifi ed on the cover:

Enter the total hours worked for 2007. (You can copy this from your OSHA Form 300A.)

Total hours worked by all employees in 2007

Note: Total Hours Worked should exclude vacation, sick leave, holidays, and other non-work time.

If needed: Steps to estimate total hours worked

STEP 1: Find the number of full-time employees in your establishment for 2007.

ABC Company had 15 full-time employees during 2007.

STEP 2: Multiply this number by the number of hours worked for a full-time employee in a year. This is equal to the number of full-time hours worked:

ABC Company’s 15 full-time employees worked an average of about 1,760 hours each per year after excluding vacation, sick leave, holi-days, and other non-work time. (The hours worked for a full-time employee in a year may be different at your reporting site)

15 (full-time employees) times 1,760 (hours worked by a full-time employee in a year) equals 26,400 full-time hours.

STEP 3: Add the number of any overtime hours and the number of hours worked by other employees (part-time, temporary, seasonal) to the amount in Step 2:

ABC Company’s full time employees worked a total of 1,500 hours of overtime. In addition, 3 part time employees worked a total of 2,715 hours during 2007. Adding these hours to those from Step 2:

Full-time hours from Step 2 26,400 Overtime hours + 1,500 Part-time hours + 2,715

Total hours worked by all employees in 2007 = 30,615

3. Check any conditions that might have affected your annual average number of employees or total hours worked during 2007:

Strike or lockout Shutdown or layoff Seasonal work Natural disaster or adverse weather conditions

Shorter work schedules or fewer pay periods than usual Longer work schedules or more pay periods than usual

Other reason: _____________________________________ Nothing unusual happened to affect our employment or hours fi gures

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Summary of Work-Related Injuries and Illnesses, 2007 Using your completed Calendar Year 2007 Summary of Work-Related Injuries and Illnesses (OSHA Form 300A):

1. Copy the establishment summary information into the spaces below.

2. If you prefer, you may enclose a photocopy of your Summary of Work-Related Injuries and Illnesses (OSHA Form 300A).

3. If any total is zero on your OSHA Form 300A, write “0” in that total’s space below.

Sign and return this form Fill in the name, title, phone number and fax number of the person we should call with questions about this form. Then sign and date the form.

Printed Name Telephone Number Ext. Fax Number E-mail address (optional)

Signature Title Today’s date

Use the envelope included with this packet to mail the original forms to us. If the return envelope is missing, send the package to the address on the front cover. Remember to keep a photocopy for your records.

Number of Days Copy these totals from columns (K) and (L):

Total number of days of job transfer or restriction (column L)

Total number of days away from work (column K)

Number of Cases Copy these totals from columns (G), (H), (I), and (J): Total number of deaths (column G)

Total number of cases with days away from work (column H)

Total number of cases with job transfer or restriction (column I)

Total number of other recordable cases (column J)

Did you have ANY occupational injuries or illnesses during 2007?

Yes. Go to the next section, Summary of Work-Related Injuries and Illnesses, 2007.

No. Go to Sign and return this form below.

Injury and Illness Types Total number of . . .

from column (M)

(1) Injuries

(2) Skin disorders

(3) Respiratory conditions

(4) Poisonings

(5) Hearing loss

(6) All other illnesses

196b2007-surveyform.indd 4 2/21/2008 12:23:32 PM

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/HRV (Za stvaranje Adobe PDF dokumenata najpogodnijih za visokokvalitetni ispis prije tiskanja koristite ove postavke. Stvoreni PDF dokumenti mogu se otvoriti Acrobat i Adobe Reader 5.0 i kasnijim verzijama.)

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<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> /ENU (Use these settings to create Adobe PDF documents best suited for high-quality prepress printing. Created PDF documents can be opened with Acrobat and Adobe Reader 5.0 and later.)

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