The Bureau of Labor Statistics of the U.S. Department of Labor is the principal Federal agency responsible for measuring labor market activity, working conditions, and price changes in the economy.
U.S. Department of Labor, Bureau of Labor Statistics
Survey of Occupational Injuries
and Illnesses, 2019
Pennsylvania Fax Response Form
Send to (717) 772-8319
Employers selected for the BLS Survey of Occupational Injuries and Illnesses are required by Federal Law to respond.
If you have questions please contact us at the phone number listed on the front of your survey instructions.
Section 1: Establishment Information
42 - 12345678901234567890 - 10 Establishment ID Number (from front of survey instructions)
Company Name and Report For (from front of survey instructions)
Contact Name and Title (please print)
Telephone Number (ext)
( ) -
( ) -
1 Enter the annual average number of employees for 2019.
2. Enter the total hours worked by all employees for 2019.
3. Did you have ANY work-related injuries or illnesses during 2019?
Yes Complete Section 2 below.
No Please fax this form to (717) 772-8319.
Section 2: Summary of Work-Related Injuries and Illnesses
1. Refer to the OSHA Forms for Recording Work-Related Injuries and Illnesses for the location referenced on the front
of the survey instructions under Report For.
2. If you prefer, you may fax your Summary of Work-Related Injuries and Illnesses (OSHA Form 300A) with this form. If more
than one establishment is noted on the front of the survey instructions, be sure to fax the OSHA Form 300A for each of the
3. If any total is zero on your OSHA Form 300A, write “0” in that space below.
4. The total number of cases recorded in G + H + I + J must equal the total injury and illness types recorded in
M (1 + 2 + 3 + 4 + 5 + 6).
Number of Cases
Total number of deaths