69-084 - 76 - 11 Gentlemen: The Occupatiora Safety and Health Act of 1970 requires the Secretary of Labor to collect, comp.ie. and analyze statistics on occupational injuries and inesses. This is accomplished through a or Federal-State survey program with States that have received Federal grants for col lecting and compiling statistics. Establishments are selected for this survey on a samole basis with varying probabilities depending upon size. Certain establishments may be included in each year's sample because of their mportance to the statistics for their industry. You have beer selected to participate in the nationwide Occupational Injuries and Illnesses Survey for 1975. Under the Occupational Safety and Heo'n Act, your report is mandatory. The following items are enclosed for your use: instructions for completing the form, (2) Form OSHA No. 103 and a copy for Please complete Form OSHA No. 103 and return it within three weeks in the If you have any questions about this survey, contact the survey collection agency indicated on Form OSHA No. 103. SURVEY REPORTING REGULATIONS Tit:e 29 Port 1904 20-22 of the Coos of Federt Regulations rea "C" FAILURE TO COMPLY WITH THE REPORTING REQUIREMENTS Change of Ownership When there has been a change of ownership during the report period, the records of the current owner and the preserved records of the previous owner are to be incorporated in the report. Explain fully under "Comments. " Partial-Year Reporting For establishments which were not in existence for the entire report year, the report should cover the portion of the period during which the establishment(s) was in existence. Explain fully under "Comments. SECTION I- ESTABLISHMENTS INCLUDED IN THE REPORT This report should include only those establishments located in, or identified by, the Report Location Identification designation which appears below your mailing address. This designation ay be a geographical area, usually a county or city, or it could be a brief description of your operation within a geographical area. If you have any question concerning the coverage of this report, please contact the agency identified on the OSHA No. 103 report form Enter in Section 1 the number of establishment s (as defined below included in this report DEFINITION OF ESTABLISHMENT An ESTABLISHMENT is defined as a single physical location where business is conducted or where services or industrial operations are performed. For example a factory, mill, store, hotel, restaurant, movie theatre, farm, ranch, bank, sales office warehouse, or central administrative office. For firms engaged in activities such as construction, transportation, communication, or electric, gas and sanitary services which may be physically dispersed, reports should cover the place to which employees normally report each day. ng calendar cf employees, SECTION II - ANNUAL AVERAGE EMPLOYMENT IN 1975 Ann. Average emp cymer should be computed by Summing the emp syme from all pay you had the following monthly employment--Jan-10; Feb. 10 Mar-10; Apr.-5. May-5; J.ne 5; July-5; Aug.-0; Sept.-0; Oct. 2, Nov.-5; Dec. 5--you would sum the number ct employees for each monthly pay period (in this case, 60) and then divide that total by 12 the number of pay periods during the year) to derive an average annual employment of 5. SECTION III TOTAL HOURS WORKED IN 1975 Enter in Section Ill the total number of hours actually worked by all classes of employees SECTION IV SUPPORT ACTIVITIES PERFORMED FOR OTHER It's necessary to know whether this report includes any establishments whose primary Answer "No" if (a) services are not the primary function of any establishment(s) included in this report or (b) if services are provided but only on a contract or fee basis for the general public or for other business firms. Answer "Yes" only if supporting services are provided to other establishments of your company. Also, indicate the primary type of service or support provided by checking as many boxes as apply. For example, if one separate establishment is a central administrative office and another is a warehouse, check both (1) and (3). If several supporting services are performed in one establishment at a single location, check the one box which best describes the primary activity. SECTION V NATURE OF BUSINESS IN 1975 не must have information Snelded in your In order to assign the appropriate rature of business coce NOTE: If more than one establishment is included 'as ind cated in Section, information Item 1: General Activity Enter the principal activity during 1975 in general terms such as manufacturing, construction, trade, finance, services, etc. - List in order of importance the specific products, lines Item 2: Specific Activity of trade, types of services, or other economic activities Provide as much detail as possible. Copos te each entry, please enter the approximate percentage of 1975 annual dollar .c've of production, sales receipts, etc.. estimates are acceptable. appropriate. as Reliable SECTION VI RECORDABLE INJURIES AND ILLNESSES Check the appropriate box. If you checked "Yes" complete the remainder questionnaire. If you checked "No" complete Section Vil and Section IX. Part B. Periodic general medica examinations-ar examination administered by c acctor er registered protess onal perst me under the standing orders of a inach medical cuinions or conclusions are drown Periodic mec: surveillance examination-periodic screening of employees SECTION VIII- INJURY AND ILLNESS SUMMARY This section can be completed quickly and easily by copying the data already entered on your OSHA No 102 "Summary of Occupational Injuries and Illnesses for 1975 c by summarizing the data from your OSHA No. 100 "Log of Occupational Injuries and Illnesses one establishment, report includes more the OSHA than NOTE: If this separate No. 102 summaries for each must be added and the sums entered in Section VII you should first make sure that each OSHA No 102 form has been cor However. 102 form is the summary rectly prepared. The OSHA No. of cases which have on the Log of Occupational Injuries and Illnesses (OSHA No. 100 been entered during calendar year 1975. Please review the Log to make sure that all entries are correct and complete. Each case should be included in only one of the three types. Fatalities (Log column 8); Lost Workday Cases (Log column 9): or Nonfatal Cases Without Lost Workdays (Log column 1C). The Summary OSHA No. 102) should have been completed by summarizing, separately, occupational injuries (code 10) and the seven categories of occupational illnesses code 21 through 29) according to instructions on the back of the Summary form Please remember that, if an employee's loss of workdays is still continuing at the time the summary is completed, you should estimate the number of future workdays he will lose and add this estimate to the actual workdays already lost. SECTION VII SUPPLEMENTARY DATA ON JOB SAFETY AND HEALTH PART A: Enter the number corresponding to the first month in 1975 in which your estabishment's had an OSHA compliance inspection. For example, if the inspection occurred in March, enter "03". If the inspection occurred in Novementer "il etc. include inspections under the Federal or State equivaler's of the Occupational Safety and Health Act by Federal or State inspectors and other inspections which may result in penalties for violations of safety standaras Do not include inspections limited to elevators or boilers or those which are consultative in nature. NOTE: Al cases which, in your judgment, required only First Aid Treatment even when administered by a doctor or "urse should not be included on this report First Aid Treatment is defined as one-time treatment and subsequent cbservation of minor scratches c burns, spinters, particles in the eye, etc. SECTION IX Please complete ali parts, including telephone number. Then return the 103 form (but NOT your file copy) in the self-addressed envelope. OSHA No. 2 THIS REPORT IS MANDATORY UNDER PUBLIC LAW 91-596 IT WILL BE USED ONLY FOR ADMINISTRATIVE AND STATISTICAL PURPOSES 1. ESTABLISHMENTS INCLUDED IN THIS REPORT VII. SUPPLEMENTARY DATA ON JOB SAFETY AND HEALTH either a Federa' or State CSA compli A. if your establishment(s) had ance inspection during calendar year 1975, please enter the month of the I first inspection This report should include only those establishments IOCated in identified by, the Repor location Identifi cation appears below your mailing andress on this form Enter the number of establishments see definition page included in this report. B. (a) Do you provide medical examinations for your employees? include the (4) approximate percent of (5) total 1975 (6) annual value of production, soles, or receipts. Legal Services Examination of employees returning to work after a lost time job related injury or illness Examination of employees upon termination of employment C. Do you have an established safety and health training program? (Check as many as apply) VI. RECORDABLE INJURIES AND ILLNESSES D. Enter the number of lost workday cases (not the number of lost workdays, (3) Storage (warehouse) (4) Other Specify: = KALE ATY LGAL SERVICES VIII. INJURY AND ILLNESS SUMMARY (Covering Calendar Year 1975) INSTRUCTIONS: This section may be completed by copying data from OSHA No. 102, 'Summary, Occupational Injuries and Code 30 Add all Occupational Illnesses (Code 21+22+23+ 24+ 25+ 26+ 29, and enter on this line for each column 1) Code 31 Add Occupational Inturies Code 10) and the sum of all Occupational Illnesses (Code 30) and enter on this line for each column: 1 through (8). Please note that first aid even when administered by a doctor or nurse, is not recordable |