OSHA Instruction October 30, 1978 PER 8.1

November 16, 1972

OSHA ADMINISTRATIVE PER 8

To: All OSHA Employees

Subject: The OSHA Safety and Health Program

Attachments: SF-92 "Supervisor's Report of Accident" SF-92a "Report of Accident other then Motor Vehicle" SF-91 "Operator's Report of Motor Vehicle Accident" SF-91a "Investigation Report of Motor Vehicle Accident" OSHA 102 F "Summary Report of Federal Occupational Injuries and Illnesses" (and instructions) OSHA 102 FF "Summary Report of Federal Occupational Accidents"

(and instructions)

1. Purpose: To inform OSHA employees of the safety and health program within OSHA and to implement the Department of Labor's Occupational Safety and Health Management Program (Chapter 5-300 of the DOL Manual of Administration).

2. Policy: It is the policy of OSHA to administer a comprehensive and continuous safety and health program to ensure the safety and health of its employees and the public, to maximize the utilization of its human and physical resources, and to minimize monetary losses, thereby advancing the overall mission of OSHA. The program will meet all standards promulgated by the Occupational Safety and Health Administration.

3. Action:

A. Responsibility:

1. The Assistant Secretary of Labor for the Occupational Safety and Health Administration is responsible for the overall management and the administration of the OSHA Occupational Safety and Health program. He shall designate a member of his staff - to be called the Safety Officer - who will be responsible for the organization, planning, development, coordination, and evaluation of OSHA Occupational Safety and Health Management activities.

2. The responsibility of each N.O. Office Director, Regional Administrator, Area Director and District Supervisor is to ensure that their employees have safe and healthful working conditions.

OSHA Instruction 2 October 30, 1978 PER 8.1

3. The responsibilities of the N.O. Safety Officer include:

a. Implementing the Department of Labor's Occupational Safety and Health Management Program, safety and health standards, policies, procedures, and programs as they pertain to OSHA programs and activities both in Washington and the field.

b. Maintaining an OSHA safety management information system which will implement and be consistent with the Department of Labor's system.

c. Investigating accidents that result in serious personal injury or major property damage.

d. Reviewing and analyzing reported OSHA occupational injuries, illnesses, and accidents to consider the adequacy of actions to prevent the recurrence of such accidents and making recommendations for improvement where necessary.

e. Serving as Executive Secretary to the OSHA Safety and Health Committee.

f. Promoting safety and health activities within OSHA by initiating specific promotional campaigns.

g. Supporting a safety and health training program for supervisors and employees.

h. Representing OSHA on the Department of Labor Safety and Health Committee.

i. Serving as liaison between OSHA and the Department of Labor Occupational Safety and Health Director on matters pertaining to Departmental safety and health problems, plans, procedures, and research and engineering projects.

j. Promoting a safety suggestion program and reviewing and evaluating all OSHA employee suggestions regarding occupational safety and health matters, and if appropriate, refer them to the Department of Labor's Safety and Health Committee.

k. Ensuring that the practice of prompt completion of employee injury compensation forms is followed within OSHA.

4. Supervisors. The supervisor will be responsible for:

a. Enforcing safety and health rules, regulations and standard

b. Instructing employees under his jurisdiction in safe practices and methods of operation.

c. Giving full support to the Occupational Safety and Health Program.

OSHA Instruction 3 October 30, 1978 PER 8.1

d. Conducting regular safety and health inspections of his operation and taking prompt corrective action whenever unsafe and unhealthful conditions and practices are noted.

e. Obtaining medical attention for injured or ill employees.

f. Encouraging and promoting employee suggestions on how to improve safety and health in the work environment.

g. Working with the Safety Officer and/or Safety Representatives in investigating accidents and completing appropriate compensation and accident prevention forms and submitting them through proper channels on a timely basis.

5. OSHA Employees. Each OSHA employee will be responsible for the safe performance of his duties and for learning and using safe and correct procedures. Constant awareness is the best protection from injury, and each employee will recognize and accept safety as a way of life.

Each employee will accept the duty of working safely, observing safety procedures, and practicing safety rules.

Employees are responsible for:

a. Remaining continually aware of the safety and health precautions necessary on their own jobs.

b. Becoming aware of unsafe and unhealthy conditions and eliminating those they can immediately.

c. Notifying the supervisor and Safety Representative immediately of unsafe and unhealthy conditions that they cannot personally correct.

d. Reporting all on-the-job accidents and illnesses to their immediate supervisors.

B. OSHA Labor-Management Safety Committee. There shall be organized within OSHA a labor-management safety committee at headquarters level.

1. Membership.

a. The Assistant Secretary of Labor for Occupational Safety and Health or his Deputy as chairman.

b. The employee designated as OSHA Safety Officer as Executive Secretary.

c. An employee designated by Labor Lodge 12 as the employee representative.

OSHA Instruction 4 October 30, 1978 PER 8.1

d. A representative from OSHA's personnel office.

e. A representative of the Office of Administrative Services, OASA, to serve as an advisor to the committee when a Department-wide safety and health problem exists, or upon request by the Committee Chairman.

f. A representative from each of the N.O. Office Directors.

2. Meetings. Meetings will be held at least quarterly or as called by the chairman. The purpose of the meetings will be to review reported accidents, to consider the adequacy of action taken to prevent the recurrence of such accidents, to appraise the effectiveness of the program, to explore the necessity for revisions of policy, instructions, or physical layout, and to assist in implementing and promoting Departmental and local safety and health programs. Copies of the minutes of the meetings shall be forwarded to the Department of Labor Occupational Safety and Health Director (OASA), committee members, and all Regional Safety Representatives.

C. Safety Representatives. Safety Representatives will assist the OSHA Safety Officer in carrying out his responsibilities. Each of the following shall appoint a Safety Representative for his organization:

1. N.O. Office Directors

2. Regional Administrators, to coordinate region-wide programs.

3. Area Directors and District Supervisors. (These Safety Representatives will be under the technical guidance of the Regional Safety Representative).

Each Safety Representative will review and analyze all accident reports, will investigate accidents or will assist the OSHA Safety Officer in the investigation of accidents, will prepare and process required reports, and will promote safety and health activities. Safety Representatives will make sure that compensation forms have been completed for injured employees.

D. Annual Safety and Health Survey. It shall be the responsibility of each Safety Representative to make an annual safety and health survey of his organization's office workspace. A report of the findings, recommendations made, and corrective actions taken shall be submitted to the OSHA Safety Officer by December 31 of each year. A consolidated report will be submitted by the Safety Officer to the Office of the Assistant Secretary for Administration and Management, Attn.: Department Occupational Safety and Health Director, by January 30 of each year.

OSHA Instruction 5 October 30, 1978 PER 8.1

1. Membership of Survey Teams.

a. National Offices.

(1) Safety Representative.

(2) Union representative.

(3) Staff member of operations being inspected.

(4) OSHA Safety Officer when requested by the Safety Representative.

b. Field.

(1) Regional Safety Representative.

(2) Union representative.

(3) Staff member of operations being inspected, or in the review of an Area or District Office, the Safety Representative of the office.

E. New Space Survey. Before moving employees into new office space, whether at the NO or in the field, a safety and health survey will be made of the building and office space, and deficiencies major in nature will be corrected. The OSHA Safety Officer and the Regional Safety Representatives will arrange for the inspection of all new space in their areas.

F. Field Federal Safety Advisory Councils. Each Safety Representative shall participate in his respective field Federal Safety Advisory Council and the OSHA Safety Officer shall participate in the Federal Safety Council for the Potomac Area.

G. Accident Reporting. (An accident is an unintended or unplanned occurrence that results in injury to personnel, property damage, production interference, or a combination of these conditions).

1. In the event of an on-the-job injury or illness, or property damage of $100 or more, the following shall be done (examples of completed forms are found in the attachment):

a. National Office

(1) Immediate Supervisor

- informs his Safety Representative;

- completes two (2) copies of SF-92 (Supervisor's Report of Accident);

- sends two copies of SF-92 to the OSHA Safety Officer;

- sees that injured employees complete compensation forms.

OSHA Instruction 6 October 30, 1978 PER 8.1

(2) OSHA Safety Officer

- receives two copies of SF-92;

- forwards the original copy to the Department Occupational Safety and Health Director (OASA);

- retains one copy of SF-92 for his files;

- when necessary investigates the accident and suggests corrective action to administration head by means of a memorandum (copies to Department Occupational Safety and Health Director (OASA) and Office Director).

b. Field

(1) Immediate Supervisor

- informs his OSHA Safety Representative (Area and District Representatives will inform the OSHA Regional Representative);

- completes four (4) copies of SF-92;

- sends four copies through channels to the Regional Representative);

- sees that injured employees complete compensation forms.

(2) Regional Administrator

- receives four copies of SF-92 (and has the copies reviewed by the Regional Safety Representative);

- sends four copies of SF-92 to the DOL Regional Safety Officer (who in turn will send two copies to the OSHA Safety Officer at the N.O. and one copy back to the OSHA Regional Office for filing).

(3) OSHA Safety Officer

- receives two copies of SF-92 from the DOL Regional Safety Officer;

- sends one copy to the Department Occupational Safety and Health Director within ten days following the receipt of report;

- retains one copy for his files;

- when necessary investigates the accident and suggests corrective action to Administration Head by means of a memorandum (copies to Department Occupational Safety and Health Director and Regional Administrator).

OSHA Instruction 7 October 30, 1978 PER 8.1

2. In the event of a motor vehicle accident - which is any occurrence involving a Federal Government-owned, leased, or rented vehicle, or privately-owned vehicle while operated on official Federal Government Business which results in death, injury or property damage of one hundred dollars ($100) or more regardless of who was injured (if anyone) or what property was damaged - the following shall be done (example of completed forms are found in the attachment):

a. National Office

(1) Operator of vehicle completes SF-91 at the scene of the accident if he is able, (if not the immediate supervisor will complete the form promptly upon being informed of the accident) and forwards to supervisor.

(2) Immediate Supervisor

- informs his Safety Representative;

- completes four (4) copies of SF-91A (five if a GSA vehicle is involved), "Investigation Report of Motor Vehicle Accident," not later than five days following the accident. Also, completes SF-91 if employee is unable to do so. Section 28 of the SF-91A shall be completed for all personal injuries resulting from motor vehicle accidents. Note: A memorandum will be attached to the SF-91A answering the following two questions concerning seat belts: were seat belts provided, and were the seat belts being used at the time of the accident;

- sends original and two copies of the SF-91A to OSHA Safety Officer;

- where a GSA vehicle is involved, one additional copy is sent to Chief of the local GSA Motor Pool;

- sees that injured employees complete compensation forms.

(3) OSHA Safety Officer

- receives three copies of SF-91A;

- sends one copy to the Department Occupational Safety and Health Director (OASA);

- sends one copy to the Office of the Solicitor;

- retains one copy for his files;

- when necessary investigates the accident and suggests corrective action to Administration Head by means of a memorandum (copies to Department Occupational Safety and Health Director and Office Director).

OSHA Instruction 8 October 30, 1978 PER 8.1

b. Field

(1) Operator of Motor Vehicle completes SF-91 at the scene of the accident if he is able, (if not his immediate supervisor will complete the form) and forwards to supervisor.

(2) Immediate Supervisor

- informs his OSHA Safety Representative (Area and District Representatives will inform the OSHA Regional Representative);

- completes four (4) copies (five if a GSA vehicle is involved) of SF-91A. Also completes SF-91 if employee is unable to do so. Section 28 of the SF-91A shall be completed for all personal injuries resulting from motor vehicle accidents. Note: A memorandum will be attached to the SF-91A answering the following two questions concerning seat belts: were seat belts provided, and, were the seat belts being used at the time of the accident;

- sends four copies to the Regional Administrator not later than three days following the accident;

- where a GSA motor vehicle is involved, sends one copy of report to Chief of local GSA motor pool;

- sees that injured employees complete compensation forms.

(3) Regional Administrator

- receives four copies of SF-91A (and has the copies reviewed by the Regional Safety Representative);

- prepares Xerox copy for files;

- sends four copies of SF-91A to the DOL Regional Safety Officer (who in turn will send two copies to the OSHA Safety Officer at the N.O. and one copy to the Regional Solicitor).

(4) OSHA Safety Officer

- receives two copies of SF-91A from the DOL Regional Safety Officer;

- forwards one copy to the Department Occupational Safety and Health Director (OASA);

- retains one copy for his files;

- when necessary investigates or has a Safety Representative investigate the accident and suggests corrective action to Administration Head by means of a memorandum (copies to Department Occupational Safety and Health Director and Regional Administrator).

OSHA Instruction 9 October 30, 1978 PER 8.1

3. Special Reporting Procedure in Cases of Death or Major Injury. The first office receiving notification of an accident which results in a fatality or major injury shall report the following information expeditiously to the Safety Officer who in turn shall transmit it within 24 hours to the Department Occupational Safety and Health Director and the Administration Head:

a. name and position (if applicable) of injured person;

b. location of accident;

c. cause of accident;

d. person to contact for further details;

e. written report must follow within 5 working days.

4. Reporting Lost Work Time. In those instances where it is not possible to know the amount of time an injured employee will lose, the accident report may be submitted without this information. When the employee returns to work, his supervisor will advise the OSHA Safety Representative of the date the employee returned to work and the total amount of time lost.

5. Non-Government Personnel. When an accident incident to an operation or activity of the Department involves an injury to a non-government person, SF-92A shall be completed in triplicate by the supervisor of the activity and all copies will be routed through the Safety Representatives to the OSHA Safety Officer. The original and one copy shall be sent to the Department Occupational Safety and Health Director (OASA), who shall forward the original to the Office of the Solicitor.

H. Injury Compensation. The Federal Employee's Compensation Act (Public Law 64-267), administered by the Office of Wage and Compensation Programs, Department of labor, provides certain benefits for Federal employees who are injured on the job or experience work-connected illnesses. For information concerning coverage and eligibility, benefits, administration and responsibility, and procedures, see Chapter 810, FPM.

I. Personal Protective Equipment. Approved personal protective equipment will be provided for employees who work under hazardous conditions. The OSHA Safety Officer will arrange for employees to receive instruction on the proper use of protective equipment. Supervisors will ensure that the equipment is used.

J. Quarterly Summary Report. The OSHA Safety Officer shall prepare a Quarterly Summary Report (Forms 102F and 102FF - see attachment) and send it to the Office of the Assistant Secretary for Administration and Management, Attn.: Department Occupational Safety and Health Director, to arrive not later than January 15, April 15, July 15 and October 15 of each year. To assist the Safety Officer, the Safety Representatives (C above) will prepare Forms 102F and 102FF for their units according to the following timetable:

OSHA Instruction 10 October 30, 1978 PER 8.1

1. National Office

a. Safety Representatives will prepare Forms 102F and 102FF for their units for receipt by the Safety Officer on the nearest workday to January 12, April 12, July 12, and October 12 of each year.

b. All units must report, even if the report is negative.

2. Field

a. Regional Safety Representatives will prepare Forms 102F and 102FF for the region for receipt by the Safety Officer on the nearest workday to January 12, April 12, July 12, and October 12 of each year.

b. Area and District Office Safety Representatives will prepare Forms 102F and 102FF for receipt by the Regional Safety Representative on the nearest workday to January 7, April 7, July 7, and October 7 of each year.

c. All units must report, even if the report is negative.

K. Annual Summary Report. The OSHA Safety Officer shall prepare an Annual Summary Report on Forms 102F and 102FF for arrival at the Office of the Assistant Secretary for Administration and Management, Attn.: Department Occupational Safety and Health Director not later than January 30 of each year.

L. Forms. The Safety Officer will distribute OSHA Forms 102F and 102FF to those who will have use for them. National Office supervisors may requisition the SF forms according to procedures found in OSHA Administrative Directive #72-56, dated July 7, 1972. Supervisors in the field may requisition the SF forms from RAO.

4. Filing. This directive is effective immediately and shall be retained until further notice.

____________________________

Assistant Secretary of Labor

A-1, B-2, C-2, D-4, E-2

(Originator: OMA)

Standard Form 92 Promulgated Dec. 1947 by Bureau of the Budget Circular A-5 (Rev.)

SUPERVISOR'S REPORT OF ACCIDENT

DO NOT USE FOR MOTOR VEHICLE OR AIRCRAFT ACCIDENT

(See Instructions on Back. Use Additional Sheets if Necessary)

_____________________________________________________________________________

Section I - Reporting Unit | ____________________________________________________________________________| 1a. TO: (Appropriate headquarters) ATTN:Safety & Health|2. ACCIDENT OCCURRED| Dir. | IN | U.S. Dept. of Labor-Wash., D.C. 20210 |____________________|

_______________________________________________________|GOVERNM'T|CONTRACTOR|

 b. FROM:(Reporting Dept., etc., & location - include  |OPERATION|OPERATION |
         town & State or foreign country               |         |          |
   Your Bureau and Office name, City and State.        |     X   |          |

_______________________________________________________|_________|__________| Section II - When, Where, How, and Why Accident Occurred and Corrective | Action |

____________________________________________________________________________| 3. DATE OF ACCIDENT | 4. TIME | 5. EXACT LOCATION OF ACCIDENT | | | | 3/29/63 |8:40 a.m.|Room 612, Engineers, Bldg., Chicago 4, Ill. |

____________________|_________|_____________________________________________| 6. DESCRIPTION BY INJURED PERSON, IF PROPERTY DAMAGE ONLY, BE PERSONS MOST | CLOSELY ASSOCIATED WITH ACCIDENT (Tell the complete story of what | happened; no signature required.) | | While walking across office to files I tripped over a small stool and fell| to the floor. Humerus bone of left arm broken. |

____________________________________________________________________________| 7. DESCRIPTION BY RESPONSIBLE SUPERVISOR - CIVILIAN OR MILITARY (What led up| to the accident, how did accident actually happen? Explain if anything | was wrong with equipment, material, or layout and what was done wrong. | Be specific.) | | Employee was carrying out assigned duties. While walking across room to | file cabinets he failed to notice small stool on floor. He tripped over | stool, fell and broke the humerus bone of left arm. |

____________________________________________________________________________| 8. WHAT ACTUALLY HAS BEEN DONE TO CORRECT CONDITIONS CAUSING THE ACCIDENT? | | Verbal and written instructions given to all employees to see that all | equipment is returned to its proper place after use. Injured employee | advised to be more observant. |

____________________________________________________________________________| 9. WHAT REMAINS TO BE DONE TO CORRECT SUCH CONDITIONS AND WHY? | Name and address of physician: | If hospitalized, name and address of hospital: |

____________________________________________________________________________| Section III - CONSEQUENCES AND RELATED DATA |

____________________________________________________________________________| 10a. INJURY TO: (Check one) |10b. PROBABLE DISABILITY|10c.ESTIMATED DAMAGE |

____________________________| (Check one) |TO PROPERTY OR EQUIP. |

REPORTING AGENCY |________________________|(Fill in 1 or more) | ____________________________|(1) DEATH |(4) TEMPOR'Y|______________________| (1)MILIT.|(2)CIVIL.|(3)CONTR| | TOTAL |(1)REPORTING |$ none | PERSNL| PERSNL| PERSNL|___________|______X_____| AGENCY | | | X | |(2) PERMN'T|(5) TEMPOR'Y|______________|_______|

_________|_________|________| TOTAL | PARTIAL |(2)CONTRACTOR*|$ " |

OTHER |___________|____________|______________|_______| ____________________________|(3) PERMN'T|(6) FIRST |(3)OTHER FED. |$ " | (4)OTHER FEDERAL|(5)NONFED. | PARTIAL| AID |______________|_______| AGENCY PERSNL| PERSON |___________|____________|(4)NONFEDERAL |$ " |

____________________________| |______________|_______| |*Contractor of | | Reporting Agency |

_____________________________________________________|______________________| 11. DESCRIPTION OF PROPERTY OR EQUIPMENT DAMAGED | None |

____________________________________________________________________________| 12. OWNERSHIP OF PROPERTY OR EQUIPMENT DAMAGED (Name and home address) | N/A |

____________________________________________________________________________| 13. NAME AND HOME ADDRESS OF INJURED |14. SEX M |16. BADGE OR SERVICE NO.| |___________| | John Doe |15. AGE 46 | Social Security No. |

_______________________________________|___________|________________________| 17. REGULAR OCCUPATION OF INJURED |18.OFFICIAL ASSIGNMENT AT TIME OF ACCDN'T| State Official Title | Give exact assignment |

__________________________________|_________________________________________| 19. NATURE OF INJURY AND PART OF |20. DATE INJURED | 21. DATE INJURED | BODY INVOLVED | STOPPED WORK | RETURNED TO WORK | Fracture - humerus bone, lft arm | 3/29/63 | Has not returned |

__________________________________|_________________|_______________________| Section IV - WITNESSES |

____________________________________________________________________________| 22. NAMES AND ADDRESSES OF WITNESSES | | Jane Smith 61 Corby Lane, City, State |

____________________________________ __________________________________ |

| ____________________________________________________________________________| Section V - SUPERVISOR |

____________________________________________________________________________| 23. DATE | TITLE (Civilian or military) | SIGNATURE OF SUPERVISOR | 3/31/63 | State official title | Richard Roe |

___________|_______________________________|________________________________| Section VI - REVIEW AND COMMENT |

____________________________________________________________________________| 24. COMMENTS ON ADEQUACY OF CORRECTIVE ACTION TAKEN, OR PLANNED, INCLUDING | PROGRESS ON PENDING ACTION | | Instructions have been issued as shown above. Safety measures to be | observed to prevent recurrence will be discussed as daily assignments | are given to staff. |

____________________________________________________________________________| 25. DATE | TITLE (Civilian or military) | SIGNATURE OF REVIEWING OFFICIAL| 4/12/63 | Exact official title | James E. Jones |

___________|_______________________________|________________________________|

INSTRUCTIONS

SCOPE: Form applies to every accident, except motor vehicle and aircraft, arising out of the operation of a Federal Department or Establishment which results in injury to a person, or damage to property.

This form may be used similarly for operations performed by contractors under the jurisdiction of the reporting department, item 1b. It is not a substitute for any report to the Bureau of Employees' Compensation, but the reverse side of Form C.A.1 of that Bureau should hereafter not be used.

PREPARATION: Answers must be given to all items on the form except as noted below: Accidents resulting in injury only, require answers to all items except 10c, 11 and 12; accidents resulting in property damage only, require answers to all items except 10a, 10b, and 13 through 21 inclusive; accidents resulting in injury and property damage require answers to all items. If a single accident involves injury to more than one person or damage to the property of more than one owner, a separate Form 92 is to be filled out for each injured person or each owner of damaged property.

SECTION I

Item 2. GOVERNMENT OPERATION. - Work performed by Government forces.

CONTRACTOR OPERATION. - Operation performed by a contractor's forces under jurisdiction of the reporting department named in item 1b.

SECTION II

Item 3. Date of accident Item 4. Hour of day or military time. Item 5. Building or other exact location. Include town and State or foreign country.

Items 6, 7. Items must provide all possible information on what happened and

a basis for answering items 8 and 9.

SECTION III

Item 10a. Injury to - Self-explanatory. REPORTING AGENCY - Department or

establishment indicated in item 1b. Item 10b. (1) DEATH. - Self-explanatory.

(2) PERMANENT TOTAL. - An injury which permanently and totally incapacitates a person from following any gainful occupation.

(3) PERMANENT PARTIAL. - An injury which results in the loss of any member or part of a member of the body, or any permanent impairment of functions of the body or part thereof to any degree less than permanent total disability.

(4) TEMPORARY TOTAL. - An injury other than the above which renders the injured person unable to perform a regularly established job on any day or shift subsequent to the day of injury (including Saturdays, Sundays, and days off).

(5) TEMPORARY PARTIAL. - An injury which prevents the injured person from performing his own job on any day or shift subsequent to the day of injury, but does not prevent his performing another regularly established job.

(6) FIRST AID (Medical Treatment Case). - An injury which requires medical treatment only and does not result in loss of time.

Item 10c. Property or equipment includes material. Give closest estimate

possible of damage; do not state "unknown," "undetermined." Each loss must be explained in item 11. (1) REPORTING AGENCY. - Department or establishment indicated in item 11.

Item 11. Include damage to material. Item 18. Work or duty assignment by supervisor at time of accident. Item 20. The date of the first day (subsequent to the date shown in item 3) when the injured commenced losing time.

Item 21. The day injured returned to work; report shall not be delayed beyond

the end of calendar month for completion of this item.

SECTION IV

Item 22. Should be "eye witnesses" if available; if not, first persons

hearing of accident from injured person or other sources.

SECTION V

Item 23. Supervisor responsible for the information in items 3-22, inclusive.

SECTION VI

ITEM 24. The designation of the reviewing official is the responsibility of

the department or establishment but should be an operating official above the level of the supervisor indicated in item 23.

____________________________________________________________________________

| REMARKS: | | | |__________________________________________________________________________|

USE ADDITIONAL PLAIN SHEETS OF PAPER IF NECESSARY

OSHA Instruction October 30, 1978 PER 8.1

SF-92a

_____________________________________________________________________________

| REPORT OF ACCIDENT OTHER THAN MOTOR VEHICLE | |___________________________________________________________________________| | DEPARTMENT OR AGENCY | ACCIDENT OCCURRED IN - | | U.S. Department of Labor, Washington, D.C. |_________________________| |_________________________________________________| GOVERNMENT | CONTRACTOR | | NAME AND ADDRESS OF LOCAL REPORTING ORGANIZATION| OPERATION | OPERATION | | Your Bureau and Office Name | X | | | City and State | | | |_________________________________________________|____________|____________| |TIME AND| DATE OF ACCIDENT| TIME |EXACT LOCATION OF ACCIDENT | |PLACE OF| | | Area in front of elevator, 1st floor,| |ACCIDENT| 11/12/65 | 12:30 PM| 18 Oliver Street, Boston, Mass. | |________|_________________|_________|______________________________________| | PERSON OR PERSONS INVOLVED | |___________________________________________________________________________| | NAMES | ADDRESSES | | John Smith | 2222 Boyleston Street | |___________________________________|_______________________________________| | | Boston, Massachusetts | |___________________________________|_______________________________________| |___________________________________|_______________________________________| |___________________________________|_______________________________________| | NATURE AND EXTENT OF INJURIES | | Bruised left knee and right arm which required first-aid treatment | |___________________________________________________________________________| | PROPERTY DAMAGED | |___________________________________________________________________________| | NAME OF OWNER | ADDRESS OF OWNER | |___________________________________|_______________________________________| | DESCRIPTION AND LOCATION OF PROPERTY | |___________________________________________________________________________| | NATURE AND EXTENT OF DAMAGE | | None | |___________________________________________________________________________| | FULL DESCRIPTION OF ACCIDENT (Use Reverse Side, If Necessary) | |___________________________________________________________________________| | There were tools scattered over the floor in front of the elevator by | | the elevator repair people, as well as a tool box and debris. John Smith | | tripped and fell over tools and debris. | | | | | |___________________________________________________________________________| | WITNESSES | |___________________________________________________________________________| | IMPORTANT. - Be particular to secure the names and addresses of witnesses,| | bystanders, or persons in the immediate vicinity who may have seen the | | accident or heard any statement made by the person injured. | |___________________________________________________________________________| | NAME | ADDRESSES | |__________________________________|________________________________________| | None | | |__________________________________|________________________________________| |__________________________________|________________________________________| |__________________________________|________________________________________| |__________________________________|________________________________________| | DATE OF THIS REPORT| TITLE OR POSITION | SIGNATURE OF PERSON EXECUTING | | | | THIS FORM | | 11/13/65 | Exact Title | Richard Roe | |____________________|___________________|__________________________________|

OSHA Instruction October 30, 1978 PER 8.1

SF-91A - INVESTIGATION REPORT OF MOTOR VEHICLE ACCIDENT

NOTE: For examples of forms to be completed for reporting motor vehicle accidents, refer to printed copy of PER 8.1.

OSHA Instruction October 30, 1978 PER 8.1

OSHA No. 102F

SUMMARY REPORT OF FEDERAL OCCUPATIONAL INJURIES AND ILLNESSES

A. This is the separate summary report for:

A.1 Civilian Personnel __

A.2 Military (Non-combat) Personnel __

B. Reporting Period __ __ - __ __ - __ __

Month Day Year (Quarter/Year Ending Date)

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| | | | Nonfatal Cases | | | | | Without | | | | Lost Workday Cases | Lost Workdays* | | | |___________________________|__________________| | Injury and | | |Number of | | |Number of | | Illness Category | | |Cases | | |Cases | | | | |Involving | | |Involving | | | | |Permanent | | |Transfer to| | |Fatal- |Number|Transfer to|Number |Number|Another Job| | | ities | of |Another Job|of Lost | of |or Termin- | | | |Cases |or Termin- |Workdays|Cases |ation of | |____________________| | |ation of | | |Employment | |Code| Category | | |Employment | | | | | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | |____|_______________|_______|______|___________|________|______|___________| | 10 |Occupational | | | | | | | | |Injuries | | | | | | | |____|_______________|_______|______|___________|________|______|___________| | 21 | Occupational | | | | | | | | | Illnesses | | | | | | | | | | | | | | | | | |Occup. Skin | | | | | | | | |Diseases or | | | | | | | | |Disorders | | | | | | | |____|_______________|_______|______|___________|________|______|___________| | 22 |Dust Diseases | | | | | | | | |of the lungs | | | | | | | | |(pneumoconioses| | | | | | | |____|_______________|_______|______|___________|________|______|___________| | 23 |Respiratory | | | | | | | | |conditions due | | | | | | | | |to toxic agents| | | | | | | |____|_______________|_______|______|___________|________|______|___________| | 24 |Poisoning | | | | | | | | |(systemic | | | | | | | | |effects of | | | | | | | | |toxic materials| | | | | | | |____|_______________|_______|______|___________|________|______|___________| | 25 |Disorders due | | | | | | | | |to physical | | | | | | | | |agents (other | | | | | | | | |than toxic | | | | | | | | |materials) | | | | | | | |____|_______________|_______|______|___________|________|______|___________| | 26 |Disorders due | | | | | | | | |to repeated | | | | | | | | |trauma | | | | | | | |____|_______________|_______|______|___________|________|______|___________| | 29 |All other | | | | | | | | |occupational | | | | | | | | |illnesses | | | | | | | |____|_______________|_______|______|___________|________|______|___________| | 30 |Total - | | | | | | | | |occupational | | | | | | | | |illnesses | | | | | | | | |(21-29) | | | | | | | |____|_______________|_______|______|___________|________|______|___________| | 31 |Total - | | | | | | | | |occupational | | | | | | | | |injuries and | | | | | | | | |illnesses | | | | | | | | | (10 plus 30) | | | | | | | |____|_______________|_______|______|___________|________|______|___________| | 40 | Total Man-hours worked by all employees_______(This Reporting Period)| | | | | 50 | Average number of employees___________(This Reporting Period) | |____|______________________________________________________________________|

 *Nonfatal Cases Without Lost Workdays - Cases resulting in: Medical
  treatment beyond first aid, diagnosis of occupational illness, loss of
  consciousness, restriction of work or motion, or transfer to another job
  (without lost workdays).

OSHA Instruction October 30, 1978 PER 8.1

INSTRUCTIONS FOR REPORT PREPARATION - FORM OSHA NO. 102F

Insert a check-mark in the appropriate square box to identify data contained in the report as either civilian or military. Please do not combine civilian and military data - submit separate reports for each group.

Reporting Period. Enter the last month and day of the current reporting quarter along with the year, in the appropriate boxes. For example, 0 3 - 3 1 - 7 2

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(Columns 1 and 2). Self-explanatory. (Column 3) Fatalities. This represents Federal employee deaths resulting from an occupational injury or illness, regardless of the time between the injury and death, or the length of illness.

(Column 4) Lost workday cases. Injuries and illnesses other than fatalities resulting in lost workday.

(Column 5) Lost workdays involving transfer or termination of employment. Insert total number of cases on the respective code line which represents lost work cases or injured or ill employees resulting in transfer to another job or termination of employment.

(Column 6) Lost workdays. Other than fatalities, lost workdays should be computed as the actual number of days the Federal employee(s) would have worked but could not because of an occupational injury or illness, i.e., an occupational injury or illness that prevented the Federal employee from performing his normal assignment. For persons still absent at end of a reporting period, estimate the expected additional number of lost workdays and include those for the quarter being reported. When the annual report is prepared, the actual number of days lost will be entered instead of the estimated figure except for those persons still absent at the end of the annual reporting period. For those still absent at the end of the reporting period, estimate expected additional lost days and include in total for the year.

(Column 7) Non-fatal cases without lost workdays. Insert the total number of cases resulting in: Medical treatment beyond first aid, diagnosis of occupational illness, loss of consciousness, restriction of work or motion, or transfer to another job (without the lost workdays).

(Column 8) Non-fatal cases without lost workdays involving transfer or termination of employment. Insert total number of cases on the respective code line which represents cases of non-fatal type without loss of work that resulted in transfer or termination of employment.

(Code 40) Man-hours worked. Insert the total hours worked by all employees on official duty at the reporting workplace during the reporting period (quarter, annual), excluding vacations, holidays, sick leave, and other nonwork time. Count only the actual hours of overtime worked. If any employee worked irregular hours or if any part-time workers were employed, care should be taken to include their actual hours worked. do not combine civilian and military man-hours worked. Please do NOT report man-days; all man-days should be converted to man-hours by the reporting agency.

(Code 50) Average number of employees. Insert the average number of full and part-time employees during the reporting period. Include all classes of employees (i.e., administrative, supervisory, clerical, professional, non-professional, technical, operating related workers, etc.). Do not combine civilian and military average number of employees.

OSHA Instruction October 30, 1978 PER 8.1

OSHA No. 102F and 102FF

1972 FEDERAL OCCUPATIONAL INJURIES AND ILLNESSES SURVEY

U.S. DEPARTMENT OF LABOR Bureau of Labor Statistics for the Occupational Safety and Health Administration Washington, D.C. 20212

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Report for the agency identified to the right

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GENERAL INSTRUCTIONS:

This questionnaire contains forms OSHA No. 102F, "Summary Report of Federal Occupational Injuries and Illnesses" and OSHA No. 102FF, "Summary Report of Federal Occupational Accidents." Both parts should be completed according to the detailed instructions on the following pages. The person completing this questionnaire should also enter the information requested below.

Refer to the November 1, 1971 booklet "Recordkeeping and Reporting Guidelines for Federal Agencies" for additional information concerning Federal Agency responsibilities under the Williams-Steiger Occupational Safety and Health Act of 1970.

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Report prepared by: Date:

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Title: Phone:

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Comments:

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Please turn page and complete 102F and 102FF forms.

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