U.S. Department of Labor           Assistant Secretary for
                                             Occupational Safety and Health
                                             Washington, D.C. 20210

OSHA Instruction CPL 2.91 MAY 13 1991 Directorate of Compliance Programs

Subject: Enhanced Verification of Records

A. Purpose. This instruction implements procedures to provide enhanced verification of the accuracy of employer's OSHA 200 Logs and Summaries of Occupational Injuries and Illnesses during general industry inspections. These procedures will be incorporated into the Field Operations Manual at the next change.

B. Scope. This instruction applies OSHA-wide.

C. References.

1. 29 CFR 1904, Recording and Reporting Occupational Injuries and Illnesses.

2. Bureau of Labor Statistics (BLS), Recordkeeping Guidelines for Occupational Injuries and Illnesses, 1986.

3. OSHA Instruction CPL 2.45B, June 15, 1989, the Revised Field Operations Manual (FOM).

4. OSHA Instruction STP 2.22A, May 14, 1986, State Plan Policies and Procedures Manual.

5. OSHA Instruction CPL 2-2.46, January 5, 1989, Authorization and Procedures for Reviewing Specific Medical Records to Verify Compliance with 29 CFR 1904.

6. OSHA Notice CPL 2, November 13, 1990, Scope of Inspection--Categories.

D. Action. Regional Administrators and Area Directors shall ensure that the procedures established in this instruction are adhered to during all general industry inspections.

E. Federal Program Change (FPC). This instruction describes a Federal program change which affects State Programs. Each Regional Administrator shall:

OSHA Instruction CPL 2.91 MAY 13, 1991 Directorate of Compliance Programs

1. Ensure that a copy of this change is promptly forwarded to each State designee, using a format consistent with the Plan Change Two-way Memorandum in Appendix P, OSHA Instruction STP 2.22A, CH-2.

2. Explain the technical content of this change to the State designee as requested.

3. Advise the State designees that OSHA believes the maintaining of accurate records of employee injuries and illnesses is the cornerstone of effective safety and health programs for both private and public sector employers. Accordingly, inspection procedures for the review of employer injury and illness recordkeeping forms are an important effort undertaken by OSHA and nationwide consistency is an integral element of this effort.

4. Ensure that State designees are asked to acknowledge receipt of this Federal program change in writing to the Regional Administrator as soon as the State's intention is known, but not later than 70 calendar days after the date of issuance (10 days for mailing and 60 days for response). This acknowledgment must include: (1) the State's intention to follow OSHA's policies and procedures described in G. and H. of this instruction; (2) a description of the State's alternative policy and/or procedure which is "at least as effective" as the Federal policy and/or procedure; or (3) the reasons why the change should not apply to that State.

5. Ensure that the State designees submit a plan supplement in response to this instruction, which will be incorporated into the FOM with the next FOM change instruction. Plan change documentation, through State FOM plan supplement, is not required to be submitted more than twice a year in response to OSHA's incorporation of Federal program changes in the FOM. If the revised manuals are issued on their target dates (April 1 and October 1), the States shall have 6 months from their issuance date to submit a plan supplement in response to the issuance of the FOM change. If an FOM change is not issued within 6 months of a change directive's issuance, follow the guidelines in paragraph I.1.a.(3)(b) of STP 2.22 A, CH-3, for the State's response.

OSHA Instruction CPL 2.91 MAY 13, 1991 Directorate of Compliance Programs

6. Coordinate with the State designees to establish a system for submitting annual evaluation reports as indicated in I. of this instruction.

7. Review policies, instructions, and guidelines issued by the State to determine that this change has been communicated to State program personnel.

F. Background. Accurate records of employee injuries and illnesses are the cornerstone of effective safety and health programs for both private and public sector employers.

1. Proper recordkeeping facilitates the identification of specific hazard areas and general trends in injuries and illnesses, which in turn leads to effective and timely hazard abatement actions.

2. The accuracy of safety and health records also has a major impact on targeting schemes developed by the Occupational Safety and Health Administration (OSHA).

a. OSHA relies on information supplied by the Bureau of Labor Statistics (BLS) to determine which industries will be targeted for scheduled inspection activity.

b. BLS in turn relies on information supplied by employers selected through statistical sampling techniques to develop relative injury and illness frequencies for the various industries.

c. The information that employers provide to BLS for this purpose comes directly from OSHA record- keeping forms maintained by the employers.

d. Improved accuracy on OSHA recordkeeping forms will lead to more effective targeting of scheduled inspections and better utilization of OSHA's resources.

3. Beginning in January 1986, OSHA made several modifications to its 1981 records check procedures that were designed to ensure that the determination of

OSHA Instruction CPL 2.91 MAY 13, 1991 Directorate of Compliance Programs

whether to conduct a comprehensive safety inspection at a general industry worksite was not based solely on the employer's injury and illness records.

4. In 1986, OSHA implemented its violation-by-violation citation and penalty procedures, resulting in increased penalties for willful violations of recordkeeping requirements. Subsequently, OSHA undertook several major recordkeeping enforcement actions which resulted in corporate-wide settlement agreements with far- reaching ramifications for improved recordkeeping.

5. In 1987, a joint pilot study was conducted by BLS and OSHA to assess injury and illness recordkeeping practices of typical employers in 193 establishments in two States, Massachusetts and Missouri.

a. Injury and illness records were reconstructed from sources other than forms required by BLS/OSHA regulations. The reconstructed records were compared with the employers' logs, and OSHA interviewed employees and designated recordkeepers.

b. The results of this pilot study showed significant underreporting of injuries and illnesses.

6. In 1988, OSHA reported to the United States General Accounting Office (GAO) its grave concern for the quality and accuracy of recordkeeping practices, but at the same time its belief that the pilot project methodology was too resource-intensive to justify use in every inspection.

7. In December 1988, GAO submitted its final report entitled "Assuring Accuracy in Employer Injury and Illness Records" to the Chairman of the Subcommittee on Labor, Health and Human Services, and Education, Committee on Appropriations of the U.S. Senate.

a. In the report GAO conceded that the pilot project was too resource-intensive for regular use, but recommended that OSHA do more to ensure the accuracy of employer records. The Agency could consider using certain, specific methods from the 1987 pilot study on a more general basis.

OSHA Instruction CPL 2.91 MAY 13, 1991 Direcorate of Compliance Programs

b. As a part of the report OSHA concurred with GAO's recommendations and agreed to incorporate improved inspection procedures for the review of employer injury and illness records.

8. OSHA has taken several steps during the past few years to improve the quality of recordkeeping by employers.

a. These actions culminated in OSHA Notice CPL 2 (Scope of Inspection - Categories) eliminating the "records only" inspection. Establishment LWDI rates are no longer used to limit the scope of inspections. The scope is determined under procedures in the FOM, Chapter II, and by workplace observations and reviews of the general and specific health and safety programs in the workplace. (See the FOM, Chapter III, D.7.c.)

b. However, emphasis continues to be given to accurate records in every inspection, and the review of records remains a factor to be considered in deciding whether and how far to expand the scope of an inspection. Appropriate citations will be issued whenever recordkeeping violations are identified.

G. Inspection Procedures. The procedures for verifying records outlined in the FOM, Chapter III, paragraph D.4.a.(4)(b), are modified to incorporate the following changes during all general industry inspections:

1. Conduct of Records Verification Check. On every general industry inspection CSHOs shall verify the accuracy of the log entries by cross-checking medical records with the OSHA-200, Log and Summary of Occupational Injuries and Illnesses, entries as stated in paragraphs G.1.a. and b., and as selected in accordance with paragraph G.4.

a. This verification procedure shall be documented in the case file, either by listing the identification number of the medical record and any corresponding entry or lack of entry on the OSHA-200 log, or by any other appropriate documentation procedure. (See G.4.a. of this instruction.)

OSHA Instruction CPL 2.91 MAY 13, 1991 Directorate of Compliance Programs

b. Additionally, the workers' compensation, First Report of Injury or OSHA-101s, shall be cross- checked with the OSHA-200 log entries.

c. The procedures outlined in OSHA Instruction CPL 2-2.46 shall be followed for access to more detailed medical records. The types of medical records which have been identified in that instruction will normally be sufficient for purposes of records verification. Appropriate training in this instruction and in CPL 2-2.46 shall be provided to compliance Safety and Health Officers to ensure that provisions of both instructions are adhered to.

d. CSHOs shall continue to calculate the LWDI rate in accordance with the FOM, Chapter III.

(1) Copies of the OSHA-200 log plus representa- tive documentation which serve to validate or invalidate the employer's recordkeeping practices, with the exception of the medical records, shall be made, if possible. If a copying machine is not available, or is not made available for CSHO's use, or the employer will not allow appropriate documents to be temporarily removed from premises, the CSHO shall follow the procedures outlined in G.1.e. and f.

(2) The CSHO must make his/her own evaluation of the medical records as they pertain to recordability of employment-related injuries or illnesses rather than copying personally identifiable medical information.

e. All actions of the CSHO taken to verify the records, including documentation of any violations, as outlined in paragraphs G.1.a.d., shall be described in the case file narrative. The description shall contain such information to explain why the CSHO checked certain records and not others, why some records were checked more extensively than others, etc.

OSHA Instruction CPL 2.91 MAY 13, 1991 Directorate of Compliance Programs

f. If the employer restricts access to certain records the CSHO considers necessary to review or if improprieties in the recordkeeping become evident, all records considered necessary for verification shall be subpoenaed and taken to the Area Office for review.

2. Employee Participation. During the opening conference, the CSHO shall ensure that the employee representa- tives, if any, are made aware of the enhanced records verification process and that the employee representatives and a specific number of other employees are asked for interviews as part of the records verification procedure.

a. The CSHO shall request input from the employee representatives to select employees for the interviews.

b. In the absence of employee representatives, the CSHO shall select a reasonable number of non-supervisory employees in different areas of the establishment, either during the inspection walkaround or a walkaround specifically for the purpose of conducting interviews for record verification.

NOTE: To ensure against unnecessary interruption of employees, as often as possible, the CSHO shall interview the same employees for records verification and for safety and health purposes and shall make every effort possible to interview at least one employee from every department/division/etc. of the workplace. However, the predominant number of interviews should be conducted with employees who work in the more hazardous areas of the facility.

c. The method of selecting employees for interviews shall be documented in the case file.

OSHA Instruction CPL 2.91 MAY 13, 1991 Directorate of Compliance Programs

3. Interview of Employees. Employee representatives shall be interviewed as well as a specific number of employees. The number of employees to be interviewed shall be a representative sample of the employees currently employed up to a maximum of 15 percent (rounded up). The 15 percent may be exceeded, if appropriate, as when major recordkeeping deficiencies are noted.

a. To the greatest extent possible, employees shall be interviewed away from their particular work location, ideally in a private company office, following the interview questionnaire in OSHA Form 185. (See Appendix A.) The good judgment of the CSHO must be applied so as not to interfere with operations more than necessary.

b. The procedures established in the FOM, Chapter III, D.8.d., on interviewing employees, are applicable.

c. The CSHO shall determine if recordable injuries/illnesses described by employees during these interviews have been recorded on OSHA forms.

d. The questions covered in the interviews shall be taken from OSHA Form 185. The format in this questionnaire shall be followed, completed in its entirety by the CSHO, and placed in the case file.

4. Number of Records to be Reviewed and Cross-checked. The number of employee records to be reviewed and cross-checked shall be based on a percentage of the number of employees employed at the establishment on the day of the inspection.

a. For each establishment, the CSHO shall review and cross-check for accuracy, a number of records not less than 10 percent (rounded down) of employees currently employed up to 25 records.

b. The 10-percent figure may be doubled in establishments with 11 to 29 employees.

OSHA Instruction CPL 2.91 MAY 13, 1991 Directorate of Compliance Programs

c. Emphasis in selecting records for review and cross-check shall be placed on the current and previous calendar year at the time of the inspection.

5. Interview of Designated Recordkeeper(s). The designated recordkeeper shall be interviewed regarding the manner in which injuries and illnesses are recorded and about the definitions, concepts, and interpretations associated with recordkeeping requirements.

a. The purpose of these interviews is to assess knowledge of the OSHA regulations and the BLS recordkeeping guidelines and to determine whether recordkeeping problems exist.

b. The questions covered in the interviews shall be taken from OSHA Form 186. (See Appendix A.) The format in this questionnaire shall be followed, completed in its entirety by the CSHO and placed in the case file.

H. Issuance of Citations. Whenever OSHA recordkeeping violations are identified, appropriate citations and penalties shall be proposed in accordance with guidelines in the FOM.

1. Citations of violations found shall be classified as other-than-serious, failure to abate, repeated, or willful violations with proposed penalties appropriate to the circumstances in each case.

2. Violation-by-violation citation and penalty procedures shall be considered, if appropriate, in accordance with OSHA Instruction CPL 2.80 and the FOM, Chapter VI, B.2.i.(4) and B.8., when flagrant recordkeeping violations are discovered.

NOTE: A full examination of records shall be undertaken if a pattern of violations is discovered.

OSHA Instruction CPL 2.91 MAY 13, 1991 Directorate of Compliance Programs

I. Evaluation. In keeping with agency policy, an evaluation of the effectiveness of the procedures implement through this instruction shall be conducted annually.

1. An evaluation report from each region shall be submitted to the Director of Compliance Programs through the Director of Field Programs within 30 days of the close of each fiscal year.

2. The report shall include, at a minimum, the following items:

a. Average amount of time required per inspection to incorporate these requirements.

c. Estimated number of violations that would have been missed without this program;

d. Number of in-compliance inspections with respect to recordkeeping; and

e. Overall usefulness and success of the procedures.

Gerard F. Scannell Assistant Secretary

DISTRIBUTION: National, Regional, and Area Offices All Compliance Officers State Plan Designees 7(c)(1) Consultation Project Managers NIOSH Regional Program Directors

OSHA Instruction CPL 2.91 MAY 13, 1991 Directorate of Technical Support

OSHA Instruction CPL 2.91 MAY 13, 1991 Directorate of Compliance Programs

OSHA Instruction CPL 2.91 MAY 13, 1991 Directorate of Compliance Programs

OSHA Instruction CPL 2.91 MAY 13, 1981 Directorate of Compliance Programs

INSPECTION CHECKLIST FOR MANAGEMENT