- Record Type:OSHA Notice
- Current Directive Number:00-07 (CPL 2)
- Old Directive Number:00-07 (CPL 2)
- Title:Audit and Verification Program of 1999 Occupational Injury and Illness Records
- Information Date:
- Standard Number:
DIRECTIVE NUMBER: 00-07 (CPL 2) | EFFECTIVE DATE: December 8, 2000 |
SUBJECT: Audit and Verification Program of 1999 Occupational Injury and Illness Records |
Purpose: | This notice establishes a program and the procedures by which to conduct audits to verify the accuracy of the data employers submit as part of the OSHA Data Initiative (ODI) and the accuracy of the underlying data on which the employer's ODI submission is based |
Scope: | OSHA-wide |
References: | OSHA Instruction CPL 2.103 Field Inspection Reference Manual (FIRM); OSHA Instruction CPL 2.111, Citation Policy for Paperwork and Written Program Requirement Violations; OSHA Instruction CPL2-2.46, Authorization and Procedures for Reviewing Medical Records |
Cancellations: | OSHA Notice 00-1 (CPL 2), 1998 Audit and Verification Program of Occupational Injury and Illness Records, December 2, 1999, is cancelled by this Notice |
Expiration Date: | One year from date of notice |
State Impact: | State Adoption not Required, See Paragraph VI |
Action Offices: | National, Regional, and Area Offices |
Originating Office: | Directorate of Information Technology, Office of Statistics |
Contact: | Dave Schmidt (202-693-1886) Directorate of Information Technology Office of Statistics Frances Perkins Building, N-3644 200 Constitution Avenue, NW Washington, DC 20210 |
By and Under the Authority of
Charles N. Jeffress
Assistant Secretary
- Purpose
- Scope
- References
- Cancellation
- Expiration Date
- Federal Program Change
- Action
- Background
- General Procedures
- Procedures to Conduct Data Check and Records Audit
- Determine the availability and location of records
- Obtain a copy of the employer's completed OSHA 200 Log
- Compare the Log Summary and the hours worked data
- Determine the audit sample size
- Review all pertinent records
- Review employer's Log
- Interview the Designated Recordkeeper
- Conduct Employee Interviews (optional)
- Issuance of Citations
- Evaluation
- Recording and Tracking
APPENDIX A Steps for Conducting the Records Audit Using ORAA
APPENDIX B Letters to Employers-1
APPENDIX C Worksheets and Questionnaires-1
APPENDIX D Coverage of Data Initiative Collection of 1999 Data
Index
- Purpose. This notice establishes a program and the procedures by which to conduct audits to verify the accuracy of the data employers submit as part of the OSHA Data Initiative (ODI) and the accuracy of the underlying data on which the employer's ODI submission is based.
- Scope. The Audit and Verification program will be conducted by Federal Area Offices or, by agreement with a State, by State personnel.
- References.
- OSHA Instruction CPL 2.103, Field Inspection Reference Manual (FIRM), 9/26/1994;
- OSHA Instruction CPL 2.111, Citation Policy for Paperwork and Written Program Requirement Violations, 11/27/1995;
- OSHA Instruction CPL2-2.46, Authorization and Procedures for Reviewing Medical Records, 1/5/1989;
- OSHA Instruction ADM 12.5A, OSHA Compliance Records, 6/28/1993;
- OSHA Instruction ADM 4.4, Administrative Subpoenas, 8/19/1991;
- OSHA Instruction CPL 2.80, Handling of Cases To Be Proposed for Violation-By-Violation Penalties, 10/21/1990.
- Cancellation. OSHA Notice 00-1 (CPL 2), 1998 Audit and Verification Program of Occupational Injury and Illness Records, is cancelled by this Notice
- Expiration Date. One year from date of notice.
- Federal Program Change. The OSHA Data Initiative (ODI) is a Federal program in which some State Plan States participate by collecting data under a contract with OSHA. States that utilize the data to focus their activities, for performance measurement, etc., have an interest in the quality of the data and are encouraged to participate in the audit program. (States which decline to participate in the audit program may choose to have Federal OSHA conduct audits in their State or may request that audits not be performed in their State.) States may conduct the audits with either compliance or non-compliance staff, as long as the personnel who conduct the audits are able to obtain access to medical records. States which have opted to participate in the Audit and Verification Program should follow the guidelines in this document, with the exception of section XI concerning citations. Although State Plan States have the legal authority to take enforcement action concerning recordkeeping violations found during audits under the State equivalent of 29 CFR Part 1904.2, they may develop alternate procedures for handling recordkeeping violations discovered during the audits.
- Action. The Regional Administrators and Area Directors shall ensure that the procedures established in this notice are adhered to in Federal enforcement jurisdictions.
- Responsible Office. Office of Statistics (OSTAT), Directorate of Information Technology
- Action Offices. National, Regional and Area Offices, State Plan States
- Information Offices. Office of Federal-State Operations, Office of Occupational Medicine
- Background. OSHA's Directorate of Information Technology, Office of Statistics has developed and implemented a system to collect and compile data on occupational injuries and illnesses for individual establishments in certain private sector industries. These data, combined with other data, will be used for OSHA's enforcement and compliance assistance programs, and to assess the results of the Agency's efforts to improve safety and health in the Nation's workplaces.
Quality assurance is an integral part of the data collection process to ensure that the data OSHA collects accurately reflect the injury and illness experience at the workplace. As a condition of the OMB clearance for the data collection, OSHA must evaluate the accuracy of data that employers submit, assess the effect(s) of the data collection on employer recordkeeping practices, and estimate the extent of employer compliance with OSHA's recordkeeping requirements.
Onsite audit of employer records is the best method to verify the accuracy of employer-maintained data on occupational injuries and illnesses. OSHA developed methods intended to facilitate the use of the audit procedures, such as statistical sampling of employees within an establishment for review of their records and computer software to help conduct and document the audit.
Approximately 700 audits have been completed prior to this year's review. - General Procedures.
- Scope. OSHA, or State personnel in States which have agreed to participate in the Audit and Verification Program, will conduct a data check and records audit on a sample of 250 establishments, selected by OSTAT using a random sampling protocol developed for the project. The sample will be chosen from the universe of establishments selected to participate in the 1999 Data Collection (approximately 80,000 establishments). The construction industry is not within this scope.
Proper SIC and size classification for the audit period (i.e. 1999 records) must be established before the audit is performed. Corporate headquarters locations with no production facilities attached should not be audited. Establishments that did not maintain an OSHA log for 1999 should not be audited. If it is determined that an assigned establishment meet any of these criteria, the audit should not be performed. Contact Dave Schmidt in the Office of Statistics and a replacement establishment will be chosen. - Inspection Procedures. For audits conducted in Federal jurisdiction, normal inspection procedures as established in the Field Inspection Reference Manual (FIRM) (CPL 2.103) will be followed, including the opening conference, records verification, employee interviews, and closing conference, with the exception that walk-around inspections will not normally be performed unless a complaint is received or the Area Director has approved the expansion of the site visit. If any complaints that are not related to recordkeeping are made to the CSHO, the CSHO will, at his or her discretion, address the complaint or refer the complaint to the Area Office for processing. Furthermore, if through review of the injury and illness records the CSHO perceives a significant safety or health hazard (e.g. multiple amputations associated with specific work process), the CSHO should contact the Area Director to obtain approval to expand the site visit to address the significant safety or health hazard.
Each data check and records audit visit will be counted as an OSHA inspection requiring the completion of an OSHA 1. Pre-inspection planning will consist primarily of a general familiarization with the size and activity of the establishment to be inspected and the entry of preliminary data into the associated software, OSHA Recordkeeping Audit Assistant (ORAA). For audits conducted in Federal jurisdiction, a medical records access order is to be obtained from the Directorate of Technical Support, Office of Occupational Medicine (OOM) prior to each inspection. OOM will be supplied with the list of establishments to be inspected. Each Area Office will be responsible for notifying OOM of the names of the personnel to be included on the access orders. Case files shall be established in accordance with ADM 12.5A. - Audit Components. As detailed in Section X, Audit Procedures, the data check and records audit shall involve:
- Comparing the 1999 Log Summary, employment and hours worked data submitted to OSHA for the data collection with the 1999 Log Summary, employment and hours worked data provided at the establishment;
- Selecting a sample of employees within the establishments;
- Reviewing available documentation concerning any injuries or illnesses for each employee selected in the sample to identify recordable cases;
- Comparing recordable cases discovered from the files of selected employees with the establishment's OSHA 200 Log to determine if the employer properly recorded cases on the Log and to identify recordable injuries and illnesses that the employer did not record (under-recording);
- Scanning the establishment Log to identify cases entered on the Log involving the selected employees that were not recordable (over-recording);
- Interviewing the establishment's recordkeeper(s) about OSHA recordkeeping requirements and their establishment's recordkeeping practices;
- Using the OSHA Recordkeeping Audit Assistant (ORAA) software system to record information gathered during the audit as described in Appendix A, "Steps for Using ORAA to Conduct the Data Check and Records Audit."
- Formal Training of Personnel. OSTAT will conduct one or more two-day training session(s) for OSHA and State personnel new to the program. The specialized training will address: the procedures for comparing the collected data with the employer's Log and for conducting the audit to verify the accuracy of records; the citation policy for the program; a review of CPL2-2.46, "Authorization and Procedures for Reviewing Medical Records"; the method for selecting a sample of employees within the establishment; and, the use of the OSHA Recordkeeping Audit Assistant (ORAA) software system for documenting and tracking audit information.
- Employee Participation. CSHOs shall involve employee representatives as outlined in Section A.2. h of Chapter II of the FIRM (CPL 2.103) in accordance with normal inspection procedures. A sample of employees will be selected for interview. If the CSHO believes the injury and illness records reviewed did not provide full and accurate information pertaining to injuries and illnesses experienced by the employees, the CSHO, shall use the procedures outlined in section X. H of this directive for conducting the interviews.
- Opening Conference. The CSHO shall present an explanatory letter and the medical access order (Appendix B) to the employer explaining the purpose, scope, and process for the data check and records audit. For audits conducted in Federal jurisdiction, the CSHO shall also inform the employer about the Agency citation policy (Section XI below) and indicate that where applicable, violations will be cited accordingly. The employer and employees shall be informed that any complaints received that are not related to recordkeeping will be addressed by the CSHO at his or her discretion or referred to the Area Office for processing.
- Closing Conference. At the conclusion of the records audit, the CSHO shall conduct a closing conference with the employer and the employee representatives. The CSHO shall describe any recordkeeping deficiencies and violations found during the data check and records audit. The strengths and weaknesses of the employer's recordkeeping program shall be discussed. For audits conducted in Federal jurisdiction, the closing conference shall follow the procedures established in the FIRM (CPL 2.103) as applicable to these inspections.
- Scope. OSHA, or State personnel in States which have agreed to participate in the Audit and Verification Program, will conduct a data check and records audit on a sample of 250 establishments, selected by OSTAT using a random sampling protocol developed for the project. The sample will be chosen from the universe of establishments selected to participate in the 1999 Data Collection (approximately 80,000 establishments). The construction industry is not within this scope.
- Procedures to Conduct Data Check and Records Audit The procedures described in this section and the referenced Appendices are included to ensure consistency in implementation of the program and to support a meaningful evaluation of the results.
- Determine the availability and location of records needed to conduct the audit (the employer's OSHA Log, employee roster, medical records, etc.).
The availability of records required for the audit and their location at the establishment are documented on a checklist in ORAA. (A hard copy is included in Appendix C.) - Obtain a copy of the employer's completed OSHA 200 Log for the establishment for calendar year 1999; the total hours worked for all employees and the average number of employees in 1999; and a copy of a complete roster of all employees at the establishment for 1999.
The employee roster should include full-time, part-time and seasonal employees. The listing may be an alphabetic listing, a payroll listing, a listing by department, or it may be in some other form. The roster must be for employees that worked during 1999. The list should not contain multiple entries for an individual.
Ask the employer for the total hours worked and the average number of employees at the establishment for 1999. If the numbers are not available, the values can be estimated as described below.
The total hours worked should be obtained for both salaried and hourly employees. The number should not include weekends (unless the employees work weekends), vacation, sick leave, holidays or any other non-work time, even if employees were paid for it. If the establishment only keeps records of the hours paid or if employees are not paid by the hour, the employer should estimate the hours that the employees actually worked. If the hours worked number is not available, use Table 1 to estimate the hours.
Table 1: Estimation of hours worked
_________ Find the number of full-time employees in the establishment for 1999 X _________ Multiply by the number of work hours for a full-time employee in a year _________ This is the number of full-time hours worked + _________ Add the number of any overtime hours as well as the hours worked by other employees (part-time, temporary, seasonal) _________ Round the answer to the next highest whole number
The average employment can be estimated as follows: Add together the number of employees the establishment paid in each pay period during 1999. Include all employees (full-time, part-time, temporary, seasonal, salaried, and hourly). Divide that answer by the number of pay periods the establishment had in 1999. Be sure to include all pay periods, even if there were no employees in that pay period. Round the answer to the next highest whole number.
Note: The average employment figure will almost always be less than the total number of employees on the employee roster due to employee turnover. - Compare the Log Summary and the hours worked data submitted to OSHA for the data collection with the data provided at the establishment.
The Submission Comparison Worksheet section of ORAA (hard copy contained in Appendix C) shall be used to compare the Log Summary and hours worked data submitted for the Data Initiative collection with the data provided by the employer at the establishment. The data submitted by employers in response to the ODI collection, including the name of the person who signed the data collection form, will be pre-entered into the worksheet for the CSHO (if the employer submitted data to OSHA). The CSHO shall enter the values from the establishment Log Summary and employment data that are provided to the CSHO at the establishment. The values should be entered exactly as recorded by the employer. Adjustments or corrections should not be made by the CSHO. The calculation of the percent difference is performed by ORAA. If there are differences in the numbers of cases reported, the CSHO shall ask the person who signed the submission why the numbers differ. If this person is not available, the question should be addressed to the recordkeeper or the manager. The response should be recorded on the Worksheet. If the employer did not submit any data, the CSHO shall ask why and record the response. - Determine the audit sample size and draw sample of employees.
The first step is to ascertain the total number of employees on the 1999 employee roster and the total number of cases recorded on the OSHA 200 Log. When these parameters are entered into the ORAA function section "Determine Audit Sample", the software will provide the number of employees whose records will be reviewed in the audit, the random start point and the sampling period.
In order to select the employees whose records will be reviewed, the CSHO shall use the 1999 employee roster. Counting down from the top of the roster, the first employee selected is determined by the "random starting point" supplied by ORAA. Continue counting down the value of the "sampling period" and note each employee selected until the sample size is obtained. For example, if the random starting point is 10, the 10th employee listed on the roster is the first selection and if the "sampling period" is 18, every eighteenth employee after the first is selected until the sample size is achieved (note: the required sample may be achieved before the end of the roster is reached).
If in identifying the sample of employees, the CSHO determines that an employee name is a duplicate or can not be used for whatever reason, he/she shall substitute the next employee name on the roster. If the CSHO comes to the end of the employee roster before obtaining the required sample size, he/she shall continue the interval count from the top of the employee roster.
The CSHO shall compile a list of the employees selected for the audit sample. (See Figure 1 for a flow diagram of the sample selection process)
NOTE: If these procedures are being used as a method of verification of the accuracy of employer's OSHA 200 Logs and Summaries of Occupational Injuries and Illnesses during general industry inspections, the CSHO may expand the scope of review beyond the employee sample at his or her discretion. When these procedures are being used to verify the quality of OSHA Log data submitted by employers under the OSHA Data Initiative, the CSHO shall not go beyond the scope of the sampled employees. - Review all pertinent records for each employee selected in the audit sample and independently reconstruct log entries for the sampled employees. Compare the reconstructed cases with the employer's OSHA 200 Log.
The CSHO shall perform a comprehensive review of the sampled employees' records in order to identify all of the occupational injuries and illnesses that may have occurred to those employees for the reference year. The records to be reviewed shall include medical records, worker's compensation records, insurance records, and if available, payroll/absentee records, company safety incident reports, company first aid logs, and/or alternate duty rosters.
For audits conducted in Federal jurisdiction, the CSHO shall conduct the review of medical records in accordance with the procedures specified in CPL 2-2.46 and in CFR 1913.10, "Authorization and Procedures for Reviewing Medical Records."
Using the various records compiled, the CSHO shall independently construct Log entries for the recordable cases identified from the employee files. The CSHO shall identify the recordable cases and enter the reasons for recordability into the ORAA. (Note: An exact calculation of days away from work and days of restricted work activity is not required. An approximation based on an initial review of the records is acceptable.) The CSHO shall then use the ORAA software to compare the reconstructed Log entries with the employer's 200 Log, and to document any differences that exist.
The CSHO shall make copies of the OSHA 200 Log for inclusion in the case file. For audits conducted in Federal jurisdiction, the CSHO shall also make copies of any documentation needed to support discovered recordkeeping deficiencies. If a copying machine is not available, or is not made available for CSHO use, or the employer will not allow appropriate documents to be temporarily removed from the premises, the CSHO shall subpoena all records considered necessary for verification using the procedures outlined in the FIRM (CPL 2.103 Chapter II. section A. 2. c. (3)) and ADM 4.4. - Review employer's log to identify any cases recorded for the sampled employees that do not meet the OSHA recordability criteria (over-recording).
After review of the sampled employees' files, the CSHO shall scan the employer's Log for any recorded cases for the sampled employees not identified in the file review. The CSHO will determine the cases' recordability by considering the documentation in the employee's records and, if necessary, talking with the employer, recordkeeper or employee. The CSHO shall document any over-recorded cases in ORAA. Documentation of over-recorded cases should be limited to cases pertaining to the sampled employees only. - Interview the Designated Recordkeeper(s).
The CSHO shall interview the designated recordkeeper(s) (a maximum of two persons) regarding the manner in which injuries and illnesses are recorded at the establishment. The purpose of this interview is to assess each recordkeeper's knowledge of the OSHA injury/illness recordkeeping requirements and to determine whether recordkeeping problems exist. The CSHO shall use the Recordkeeper Questionnaire, and should enter responses into ORAA. (A hard copy is included in Appendix C.) If the CSHO learns of any company policies that may have an effect on the injury and illness records, it should be noted in the comments section of the questionnaire. For example, if the CSHO learns there is an awards program tied to the number of injuries and illnesses recorded on the OSHA Log, the program is to be described in the comments section. - Conduct Employee Interviews.
Employee interviews using the following procedures are recommended if the CSHO believes the injury and illness records reviewed did not provide full and accurate information pertaining to injuries and illnesses experienced by the employees. A sub-sample of employees to be interviewed should be selected from the list of employees selected for the audit sample in section X.D above. The suggested number of employees to be interviewed is contained in the Employee Questionnaire function of ORAA. The questionnaire to be used in the interview is the Employee Questionnaire. Responses to the questionnaire are entered into ORAA. (A hard copy is included in Appendix C.) - Determine audit results.
Upon completion of the audit, the CSHO shall use ORAA to generate a summary of the audit findings, including the percent of cases over-recorded and under-recorded. This summary can be used in the closing conference in discussing the audit findings with the employer and should be included in the case file as part of the audit documentation.
- Determine the availability and location of records needed to conduct the audit (the employer's OSHA Log, employee roster, medical records, etc.).
- Issuance of Citations WheneverOSHA recordkeeping violations are identified by Federal personnel conducting audits within their Federal enforcement authority, appropriate citations and penalties shall be proposed, and supporting documentation shall be provided, in accordance with guidelines in the FIRM (CPL 2.103) and CPL 2.111.
- Citations of violations found shall be classified as other-than-serious with proposed penalties appropriate to the circumstances in each case. If violations are characterized as "willful," "repeat," or "failure to abate," the Regional Administrator or Regional Solicitor should be contacted for guidance.
- Violation-by-violation citation and penalty procedures shall be considered, if appropriate, in accordance with OSHA Instruction CPL 2.80 and the FIRM (CPL 2.103).
- Employers shall not be cited for over-reporting of cases. The employer shall be informed of such over-reporting and the need to eliminate these identified cases on the employer's OSHA 200 Log.
- The primary purpose of the Audit and Verification Program is to assure the statistical accuracy or the data collected under the ODI and employers generally will not be cited for violation of 1904.17 for failure to submit data to OSHA or for discrepancies found in their Data Initiative submission compared to the establishment's OSHA 200 Log, employment and hours worked data as part of the audit inspection.
- When OSHA recordkeeping violations are identified by Federal personnel conducting audits of employers within the State's authority to enforce, and are unaccompanied by State personnel, such apparent violations should be referred to the appropriate State plan.
- When OSHA recordkeeping violations are identified by State personnel conducting audits or accompanying a Federal auditor in their State, the State's procedures developed in accordance with section VI. of this document regarding the handling of such violations should be followed.
- Other violations shall be cited, as appropriate, for a limited scope inspection.
- Evaluation. The Area Director will provide OSTAT with an ORAA data file of the audits. The file can be submitted by e-mail or on a floppy disk.
In a final report, OSTAT will summarize the findings of the audit project, including (but not limited to) the accuracy of the data that employers submitted to OSHA for the data collection, employer knowledge about OSHA injury/illness recordkeeping requirements, and the level of compliance with 29 CFR Part 1904. - Recording and Tracking. In accordance with the FIRM change: "Mandatory Collection of OSHA 200 and Lost Workday Injury and Illness (LWDII) Data During Inspections" implemented by a Deputy Assistant Secretary Memorandum to the Regional Administrators dated June 21, 1996, the CSHO shall enter the summary line of the employer's OSHA 200 Log and the hours worked for three prior calendar years into the IMIS.
Item 24 of the OSHA 1, inspection type, should be coded as "k. Planned -- Other." Item 35 of the OSHA 1, scope, should be coded as "b. Partial Inspection." To facilitate tracking of these inspections for evaluation of the program, an IMIS code of "RKAUDIT" will be entered in the Optional Information block No. 42 of the OSHA-1.
Type ID Value N 16 RKAUDIT
SUMMARY OF
STEPS FOR CONDUCTING THE DATA CHECK AND RECORDS AUDIT USING THE OSHA RECORDKEEPING AUDIT ASSISTANT (ORAA) SOFTWARE
The ORAA software system has been developed to facilitate conducting, documenting, and analyzing the results of injury/illness recordkeeping audits. Table A-1 displays steps in the audit process along with the corresponding ORAA function. More detailed documentation and information is included in the HELP function of the software.
USING ORAA IN CONDUCTING THE DATA CHECK AND RECORDS AUDIT
Audit Step or Task | ORAA Function to Use | ||||
Enter information about the establishment and the contacts used during the audit. |
|
||||
Compare Log Summary and employment data from the OSHA data collection with the data provided at the establishment. |
|
||||
Determine and document the availability and location of the records needed for the audit. |
|
||||
Determine the number of employees whose records must be reviewed and select the audit sample. |
|
||||
Reconstruct log entries from the review of sampled employee records. |
|
||||
Compare the reconstructed or auditor-identified cases with the cases on the employer's OSHA 200 Log. |
|
||||
Identify and document over recorded cases. |
|
||||
Interview the establishment's designated recordkeeper(s). Record their responses. |
|
||||
Select a sample of employees for interview and record their responses. |
|
||||
Summarize findings of the audit. |
|
LETTER TO EMPLOYERS
Included in this appendix are two sample letters to be given to the employer during the opening conference. One letter is a sample cover letter to be attached to the medical access order to be presented to the employer. This letter briefly explains the basic requirements of 1910.1020 and 1913.10 The other letter briefly explains the reason for the audit and the audit procedures.
Note: Electronic copies of these letters are available in ORAA. To access these files, use the CPL button on the Main Menu of ORAA then choose Appendix B. The contents of the letters can be copied by blocking the desired text and choosing "Copy" from the Edit function of the software.
Dear (Employer):
Your workplace has been scheduled for a records audit as part of OSHA's initiative to assess the quality of data collected from employers. This letter explains how your establishment was selected for an inspection under this program and the procedures that will be followed in the records audit.
Your establishment was selected for the records audit, using a statistically random approach, from a list of establishments required to submit 1999 injury and illness data to OSHA. As part of the review to verify the accuracy and completeness of your company's 1999 OSHA 200 Log, the OSHA compliance officer will ask you to furnish the following information:
- Employee roster(s)
- Your OSHA 200 Log
- Workers' Compensation First Reports of Injury for a sample of employees
- Medical records for a sample of employees (To protect the privacy of medical records, a formal written Access Order is attached. It explains this process more fully).
- The total number of hours worked by your employees
- The average number of persons employed
In addition, the compliance officer will ask to see other related records for some employees, as needed, such as nurse/doctor/clinic logs, company first aid reports, company accident reports, insurers' accident reports, accident and health benefit insurance records, within-plant employee transfer records, absentee records, and employee/payroll records.
As part of the recordkeeping audit, the compliance officer may talk with several of your employees. We will make every effort to avoid disruption of your workplace activities and would, therefore, prefer to interview employees away from their particular work stations.
Only a recordkeeping inspection will be conducted at this time. We appreciate your cooperation in this program. If you have any questions, your compliance officer is available to discuss them with you.
Sincerely,
Area Director
Attachment
Sample Cover Letter
Dear (Employer):
The Assistant Secretary of Labor for Occupational Safety and Health has approved a formal written access order authorizing access by certain OSHA staff to specific medical records. A copy of that order accompanies this letter.
The Occupational Safety and Health Act of 1970 authorizes OSHA access to records, including employee medical records during the course of inspections and investigations conducted under the Act. The Agency recognizes, however, that there are often substantial personal privacy interests involved with employee medical records. Thus, the Agency has promulgated strict administrative procedures set forth in 29 CFR Part 1913 that govern OSHA's access to personally identifiable employee medical records, and protect legitimate privacy interests. These regulations govern when and how OSHA will seek access to medical records, who can use this information and for what purposes, and how OSHA will safeguard these records once they are in the Agency's possession.
The written access order which accompanies this letter is the result of careful Agency consideration of these matters as they apply to your worksite. The written access order states what is being requested and why; who is authorized to review and analyze the information obtained; and other matters that inform you of OSHA's actions regarding access to these medical records.
If you, or your employees or their representatives have questions or objections concerning the written access order, you should feel free to contact the Principal OSHA Investigator or the OSHA Medical Records Officer, whose names, addresses and telephone numbers are listed on the written access order.
Government access to personally-identifiable medical information will be limited to that which is necessary to carry out this investigation. The goal of the investigation is to verify the accuracy and completeness of recordkeeping practices related to ensuring safe and healthful working conditions for employees of your establishment. All medical information will be protected under the provisions of the OSHA Medical Records Access Regulation. Your cooperation will be appreciated.
Sincerely,
Area Director
WORKSHEETS AND QUESTIONNAIRES
Appendix C contains the following components:
- Submission Comparison Worksheet
- Records Identification Worksheet
- Recordkeeping Procedures Questionnaire
- Employee Interview Questionnaire (Optional)
The Submission Comparison Worksheet is used to record differences found between the Log Summary and employment data (average employment and hours worked) that the employer submitted to OSHA for the Data Collection and the data provided by the employer during the audit at the establishment. If the employer did not submit any data, complete only Section 3.
1. Establishment Information from the Establishment Data System (EDS)
Except for the inspection identification number, the establishment information printed below is from the Establishment Data System (EDS) and other data that employers submitted for the OSHA Data Collection.
Enter the inspection ID number assigned to the audit. If any of the other information is incorrect, indicate the appropriate changes next to the item.
Inspection Identification Number: | SIC: | |
Establishment Name: | ||
Facility Address: | ||
Mailing Address: | ||
Individual at the establishment who signed the data submitted to OSHA | ||
Name: | ||
Title: | ||
Telephone Number: |
2. Comparison of 1999 Log Summary and Employment Data: Submitted to OSHA and Provided During the Audit
Fill in the Log Summary, average employment, and total hours worked numbers provided to you for the audit only if the values differ from those in the "value submitted to OSHA" column. You do not have to calculate the percent difference.
Data Element | (1) Value Submitted to OSHA |
(2) Value Provided During Audit |
(3) Difference (1) - (2) |
Percent Difference ---- x 100 (2) |
Average employment | ||||
Total hours worked | ||||
col 1. Deaths as a result of injury | ||||
col 2. Injuries with days away from work or restricted workdays or both | ||||
col 3. Injuries with days away from work | ||||
col 4. Total days away from work due to injury | ||||
col 5. Total days of restricted work activity due to injury | ||||
col 6. Injuries without lost workdays | ||||
col 7a. Skin diseases or disorders | ||||
col 7b. Dust diseases of the lungs | ||||
col 7c. Respiratory conditions due to toxic agents | ||||
col 7d. Poisoning | ||||
col 7e. Disorders due to physical agents | ||||
col 7f. Disorders associated with repeated trauma | ||||
col 7g. Other occupational illnesses | ||||
col 8. Deaths as a result of illness | ||||
col 9. Illnesses with days away from work or restricted workdays or both | ||||
col 10. Illnesses with days away from work | ||||
col 11. Total days away from work due to illness | ||||
col 12. Total days of restricted work activity due to illness | ||||
col 13. Illnesses without lost workdays |
3. Employer Explanation for Differences: 1999 Log Summary and Employment Data Submitted to OSHA and Data Provided During the Audit.
If there are differences between the 1999 Log Summary and employment data submitted to OSHA for the Data Collection and the data the employer provided during the audit, or if the employer did not submit any data, ask to talk with the individual identified in section 1 of this worksheet who signed the submission to OSHA. Ask that individual (if not available, the manager or recordkeeper) "Why are the numbers different?" Record the response in the space below.
A) Differences in hours worked:
B) Differences in the number of recorded cases:
C) Other differences (e.g. average number of employees, number of days away from work, etc.):
This worksheet is included in the ORAA software system under the Track Audited Establishments function on the Main Menu. The worksheet is used to document the availability of particular types of records that the employer indicates will be made available for the audit and their location.
Records | Person- nel Office |
Safety Office |
Payroll Office |
Medical Center |
Super- visor's Office |
Other- specify |
OSHA 200 Log | ||||||
Employee roster (e.g., payroll) | ||||||
OSHA No. 101 or Workers' Compensation equivalent (log related) | ||||||
State workers' compensation forms (independent of the OSHA No. 200 and 101) | ||||||
Medical records | ||||||
Nurse/doctor/clinic logs | ||||||
Company first aid reports | ||||||
Company accident reports | ||||||
Insurers' accident reports | ||||||
Accident and health benefit insurance | ||||||
Absentee records | ||||||
Union records | ||||||
Other (specify) |
This questionnaire is included in the ORAA software system under the Recordkeeping Procedures Questionnaire Function on the Main Menu. The questionnaire is used to record responses to the interview with the manager and the recordkeeper.
OSHA Recordkeeper Questions
(Name) | Last: | First: | Middle: | |
Title: | ||||
Date: |
- In keeping the OSHA records, which of the following do you use (Check all that apply):
[ ] a. The OSHA Regulation 29 CFR Part 1904
[ ] b. Instructions on the OSH forms
[ ] c. Recordkeeping guidelines (Blue book)
[ ] d. Trade association guidelines
[ ] e. Insurers' guidelines
[ ] f. Other (list) - Do you have a computerized recordkeeping system?
[ ] Yes [ ] No - a. Does this company have other facilities?
[ ] Yes [ ] No
b. If yes, do you use centralized recordkeeping? - Do you have a completed Log and Summary of Occupational Injuries and Illnesses, OSHA No. 200, for the calendar year 1999?
[ ] Yes [ ] No - a. Do you have a completed supplementary record for each case entered on the log?
[ ] Yes [ ] No
b. If yes, which form(s) do you use as the supplementary record? - How do you get information about workplace injuries and illnesses? For example, are supervisors required to report to you any injury or illness that occurs?
- a. Are you the person normally responsible for determining whether or not a case is recordable?
[ ] Yes [ ] No
b. If not, who is? ________________________ - How were you trained to handle the duties of completing the OSHA Log?
[ ] Self taught/no formal training
[ ] Trained by supervisor, colleague, or previous recordkeeper
[ ] Classroom training
[ ] Other (please specify)_______________________________________ - If you need assistance in determining if a case should be recorded, how is it obtained?
- Do employees of your establishment request access to the OSHA log?
[ ] Frequently [ ] Occasionally [ ] Never - Recording criteria for work related injuries includes:
• All injuries are recordable [ ] Yes [ ] No • Visit to doctor for observation only [ ] Yes [ ] No • First aid [ ] Yes [ ] No • Medical treatment [ ] Yes [ ] No • Loss of consciousness [ ] Yes [ ] No • Restricted work activity [ ] Yes [ ] No • Days away from work [ ] Yes [ ] No - Recording criteria for work related illnesses includes:
• Illnesses are recordable only when they meet the same criteria for recording injuries [ ] Yes [ ] No • All illnesses are recordable [ ] Yes [ ] No - Criteria used to distinguish between injuries and illnesses for OSHA recordkeeping purposes includes:
• Length of event or exposure
(instantaneous vs non-instantaneous)[ ] Yes [ ] No • Type of condition
(e.g. laceration vs infection)[ ] Yes [ ] No - Criteria to determine if an injury or illness is work related for OSHA recordkeeping purposes includes:
• It occurred on employer's premises [ ] Yes [ ] No • Workers' Compensation decides [ ] Yes [ ] No • Only if it occurred while the employee was on the clock [ ] Yes [ ] No • Its is caused by work [ ] Yes [ ] No • It is contributed by work [ ] Yes [ ] No • It is aggravated by work [ ] Yes [ ] No - What constitutes restricted work activity for OSHA recordkeeping purposes?
• Cannot work full shift [ ] Yes [ ] No • Cannot perform scheduled duties [ ] Yes [ ] No • Cannot perform all duties employee would perform throughout the year [ ] Yes [ ] No • Doctor's note with restrictions that does not affect the employee's ability to perform all duties [ ] Yes [ ] No - a. Does your company use temporary employees?
[ ] Yes [ ] No
b. If yes, does your company supervise them on a daily basis?[ ] Yes [ ] No
c. If yes, do you record their injuries and illnesses on your OSHA log?
[ ] Yes [ ] No
(1) [ ] OSHA 101 (2) [ ] State Workers' Compensation Form (3) [ ] Insurer's Form (4) [ ] Other |
This questionnaire is included in the ORAA software system under the Employee Questionnaires Function on the Main Menu. The questionnaire is used to record responses to the interviews with a sample of employees.
Name/Employment Information
Last: | First: | Middle: | ||
Date: | Occupation (regular job title): | Tenure (length of time on the job): | ||
Department/Division: |
Recordkeeping Questions
- a. Have you ever seen an OSHA 200, the Log and Summary of Occupational Injuries and Illnesses, for your establishment?
[ ] Yes [ ] No
b. If yes, did you see it by:
[ ] Viewing the summary portion of the log posted by the employer. [ ] Requesting access to see the entire OSHA log. - Did you experience an injury or illness during 1999 that was caused or aggravated by an event or exposure in your work environment?
[ ] Yes (go to Question 3) [ ] No (go to Question 7) - Briefly describe this injury and/or illness.
- a. Did you report the injury or illness to your employer?
[ ] Yes [ ] No
b. If yes, was the case recorded on the OSHA log?
[ ] Yes [ ] No [ ] Don't Know
c. If no, why not? - Have you or your employer filed for workers' compensation for this injury or illness?
[ ] Yes [ ] No - a. a. Did your injury and/or illness involve any days away from work or days of restricted work activity? If yes, explain.
[ ] Yes [ ] No
b. If yes, how many workdays?
_____Number of days away from work _____Number of days restricted work activity - a. Are you aware of any of your coworkers experiencing a job-related injury or illness during 1999?
[ ] Yes [ ] No
b. If yes, who?
Coverage of Data Initiative Collection of 1999 Data
The scope of the Data Initiative determines the scope of the establishments to be audited. If the establishment falls outside of these parameters, do not do the audit. A replacement unit will be selected. The following is the scope of the Data Initiative collection of 1999 data. If you are unsure if an establishment falls within the scope of the collection, contact the Office of Statistics at 202-693-1886.
- Establishments with 40 or more employees in SICs 0181 and 0182. These industries had a 1997 lost workday injury and illness rate is 5.0 or greater and were not included in previous data initiative collections;
- Establishments with 40 or more employees in all SICs previously subject to ODI collections who were not included in last year's data collection (SIC reclassifications, births, newly discovered establishments, etc);
- Pilot collection in Hospitals (SIC 8060), Post Office (SIC 4311) and Department Stores (SIC 5311);
- Nonrespondents in the CY 1998 data collection;
- Establishments that are of interest to the OSHA strategic plan (Federal and State):
- Collection of follow up data on establishments that were inspected or had a consultation visit during FY 1999;
- All establishments in SIC 2411 with 11 or more employees;
- All units that reported a lost workday injury and illness rate of 7.0 or higher in the CY 1996, CY 1997 or CY 1998 data collection;
- There are about 150,000 establishments in the frame of the data initiative defined by the employment size (40 or more employees) and industries covered (see attachment 7). This year, collection will be from all establishments in the top one third. By the top one third we mean the industries with the highest lost workday injury and illness rates that contain approximately 50,000 of the establishments. This year we will collect the third from the industries with the highest rates. Next year we will collect for the middle third and the following year we will collect from the bottom third;
- Collection of public sector units in State Plan States;
- Collection by the state in addition to the 80,000 clearance requested by OSHA. 250 additional units to be collected in Hawaii; 400 in Virginia; 375 in Minnesota; and 800 public sector units in Connecticut.
- In North Carolina collect from all employers with 40 or more employees in the following industries: SICs 0782, 0783, 2091, 2092, 3710 and 3732.
- In California collect from all employers with 40 or more employees in the following industries: SICs 1721, 1751, 1752, 1761 and 4950.
- In Kentucky collect from all employers with 40 or more employees in the following industries: 2010, 2430, 3440, 3580, 3630 and 3710.
Average Number of Employees
Citations
Closing Conference
CPL 2.111
Determine the Audit Sample Size
Employee Interviews
Employee Representatives
Employee Roster
FIRM
Hours Worked
IMIS
Interview the Designated Recordkeeper
Medical Records
Medical Records Access Order
Opening Conference
Optional Information Block
ORAA
ORAA Data File
OSHA 1
Over-recording
Records Review
Report
Sample Establishments
State
Submission Comparison Worksheet
Training