Notification of Requirement to
Participate in the Survey of
Occupational Injuries and Illnesses-2004
U.S. Department of Labor
Bureau of Labor Statistics
UNIVERSITYC ºf
| 13 FA
JAN 1 9 2004
DEPOST !
UNITED STATES lºga
IMPORTANT
OSHA has issued revised recordkeeping regulations and revised forms
which are effective January 2004. The revisions to the Log and Summary
forms reflect new recording criteria for cases involving occupational
hearing loss. Also, the positions of the columns used to record lost days
have been reversed. A copy of the OSHA recordkeeping requirements
and forms is included inside for your convenience.


Dear Employer:
The U.S. Bureau of Labor Statistics is working with State agencies to survey employers about work-related
injuries and illnesses. You have been selected to participate in the mandatory Survey of Occupational
Injuries and Illnesses for calendar year 2004 (OMB No. 1220-0045, approval expires 10-31-04). In order to
obtain complete and accurate information about the safety record of America's work places, our survey must
include a sample of all establishments, regardless of size and industry. Thus, some establishments who are
normally exempt from keeping the enclosed OSHA records are included in the survey and must keep records
for the survey year. This year, we are notifying all survey participants in advance, including those who
normally keep OSHA records.
Beginning January 2004, record any work-related injuries and illnesses that occur in your workplace during
2004 according to the revised OSHA recordkeeping regulations. This package contains copies of the new
OSHA recording forms and instructions you will need to keep records of any work-related injuries or
illnesses which occur during 2004.
This package contains:
1. Our letter and instructions to participating employers and contact information "If you need help"
2. The revised OSHA Forms for Recording Work-Related Injuries and Illnesses containing:
• Log of Work-Related Injuries and Illnesses (OSHA Form 300)
• Summary of Work-Related Injuries and Illnesses (OSHA Form 300A)
• Injury and Illness Incident Report (OSHA Form 301)
PLEASE NOTE: OSHA revised the Occupational Injury and Illness recording forms for 2004, as
noted in their enclosed booklet. Revisions were made to the OSHA Log form and the year-end
summary form employers are required to complete which includes information about the employment
and hours worked at your establishment.
You will be mailed the survey form entitled Survey of Occupational Injuries and Illnesses early in 2005.
You will then be asked to copy the 2004 year-end summary information and mail the completed Survey to
us. At that time, we will also ask for details about individual cases of injury or illness. The Bureau of Labor
Statistics and the State agency collecting this information will use the information you provide for statistical
purposes only. To the full extent permitted by law, the information will be held in confidence and will not be
disclosed without the written consent of your establishment.
Your participation in the recordkeeping activity and the Survey is mandatory under Public Law 91-596. If
you have questions regarding your responsibilities for this Survey, or if you need help in recording the
information we request, call the phone number listed for your State on the back page. In addition, OSHA
has provided a list of phone numbers by State for questions regarding the OSHA recordkeeping
requirements, which are included in their booklet.
Thank you for helping us collect accurate information and for helping in the effort to make America’s work
places safer and healthier.
Bureau of Labor Statistics
U.S. Department of Labor
What do you need to do?
• Maintain the information required for all recordable work-related injuries and illnesses that
occur during the calendar year 2004 for the establishment(s) identified on the cover under
Reporting Site.
• Keep these records and use them to complete the Survey of Occupational Injuries and
Illnesses that we will send you early in 2005.
• The OSHA booklet Forms for Recording Work-Related Injuries and Illnesses provides
instructions for filling out the Log of Work-Related Injuries and Illnesses (OSHA Form 300),
as well as information about which injuries and illnesses should be recorded. During 2004,
you are required to maintain the Log of Work-Related Injuries and Illnesses (OSHA Form
300) contained in the OSHA booklet provided.
• Please do not send the Log to us. Keep it at your establishment, entering the information
required whenever an incident occurs throughout 2004.
• At the end of 2004, complete the OSHA Summary of Work-Related Injuries and Illnesses
(OSHA Form 300A) according to the OSHA directions, even if you had NO work-related
injuries or illnesses.
• Early in 2005, you will be mailed the Survey of Occupational Injuries and Illnesses and
asked to copy the data you recorded on the OSHA Form 300A. We also will ask you to
provide some additional information for selected cases as described below.
sº º' sººººººººº. ſº º Ǻx tº
* º sº ºf §§ º § º:*"º. º §º W & §§ º §
º Nº º Bºº. gº §º sº º
§§ §§§ tºº § §: ºś § sº.
sº º 㺠--- sº 5 ºr ººzºº º gº º * * - .
- ºr said iš - º s §§ º §§ º º sº § §: ?
What will the Survey o
Illnesses require you to do?
• When you receive your Survey, we will ask you to copy the summary data you have
recorded on the OSHA Form 300A included in this package. You also will be asked
to provide:
X Information about some of your injured workers, such as approximate
length of service, occupation, age, and race or ethnic background.
X- Details about the incident, such as time of day it occurred, the time the
employee started work, what the injury or illness was, what happened,
and what object or substance directly harmed the employee.
• Most of the additional information we will request in the Survey is recorded on the OSHA
Injury and Illness Incident Report (OSHA Form 301) or on Workers’ Compensation forms
that you already maintain. If so, you will be allowed to omit certain portions of the Survey.
Instead, you can send us copies of the appropriate Workers’ Compensation forms or OSHA
Form 301.
• If you have any questions about your responsibilities for this mandatory survey, go to If You
Need Help... on the back page and call the phone number listed for your State.








If You Need Help. . .
If you have any questions or if you need help, call the phone number that is listed below for your State.
The phone number may be for an office outside of your State, but they will be able to help you.
Alabama
(334) 242-3460
(334) 240-3417 fax
Alaska
(907) 465-4539
(907) 465-2101 fax
Arizona
(602) 542-3739
(602) 542-6360 fax
Arkansas
(501) 682–4542
(501) 682-4754 fax
California
(415) 703-3020
(415) 703-3029 fax
Colorado
(816) 426-2483
Connecticut
(860) 566-4380
(860) 566-1731 fax
Delaware
(302) 761-8221, 8223
(302) 761-6605 fax
District of Columbia
(202) 442-5920, 5930
(202) 442-4833 fax
Florida
(850) 413-1611
(800) 219-8953
(850) 922-0024 fax
Indiana
(317) 232-2668
(317) 233-3790 fax
lowa
(515) 281-3661
(515) 242-5076 fax
Kansas
(785) 296-5642
(785) 291-3612 fax
Kentucky
(502) 564-3070
ext. 277
(502) 564-1682 fax
Louisiana
(225) 342-3126
(225) 342–3269 fax
Maine
(207) 624-6453
(207) 624-6450 fax
Maryland
(410) 767-2373
(410) 333-7909 fax
Massachusetts
(617) 727-3593
(617) 727-5726 fax
Michigan
(517) 322-1848
(517) 322–5117 fax
New Hampshire
(617) 565-2302
(617) 565-3847 fax
New Jersey
(609) 633-0755
(609) 633-0618 fax
New Mexico
(505) 827-4230
(505) 476-8566 fax
New York
(212) 352-6688, 6691
(212) 352-6711 fax
North Carolina
(919) 733-2758
(919) 733–2186 fax
North Dakota
(312) 353–7253
(312)353–7230 fax
Ohio
(312)353–7253
(312) 353–7230 fax
Oklahoma
(405) 528-1500 ext. 257
(405) 528–3412 fax
Oregon
(503) 947-7030
(503) 378-3134 fax
Pennsylvania
(215) 861-5637, 5638
(215) 861-5736 fax
Georgia
(404) 679-0687 ext. 114,
117
(404) 679-5818 fax
Guam
(671) 647–6521
(671) 647–6516 fax
Hawaii
(808) 586-9001
(808) 586-9022 fax
Idaho
(415) 975-4473
(415) 975-4472 fax
Illinois
(217) 524-2098
(217) 557-5152 fax
Minnesota
(651) 284-5428
(888) 589-6322
(651) 284-5726 fax
Mississippi
(404) 562-2518
(404) 562-2542 fax
Missouri
(573) 751-2719, 2663,
3802
(573) 751-2319 fax
Montana
(800) 541-3904
Nebraska
(402) 471-3547
(800) 599–5155
(402) 742-2352 fax
Nevada
(775) 684-7081
(775) 687-3826 fax
Puerto Rico
(787) 754-2467
(787) 765-4687 fax
Rhode Island
(401) 462-8820
(401) 462-8766 fax
South Carolina
(803) 734-9653, 4298
(803) 734–9772 fax
South Dakota
(312)353–7253
(312) 353–7230 fax
Tennessee
(800) 778-3966
(615) 741-1748
(615) 253-5501 fax
Texas
(866) 237-6405 toll free
(512) 804-4652 fax
3 9015
UNIVERSITY OF
Utah
(801) 530-6926, 68.23
(801) 536-7906 fax
Vermont
(802) 828-5076
(802) 828-2195 fax
Virgin Islands
(340) 776-3700 ext. 2135
(340) 777-4803 fax
Virginia
(804) 786-8011
(804) 786-84.18 fax
Washington
(360) 902-5640
(360) 902-5529 fax
West Virginia
(304) 558–3322
(800) 652-9033
Wisconsin
(800)884-1273
(608) 266-3058 fax
Wyoming
(866) 518-6680
(307) 473-3863 fax
İill
6668