11
MANUAL
OCCUPATIONAL
SAFETY AND HEALTH
ENVIRONMENTAL PROTECTION AGENCY
Wash ingt o n, D. C. 20460
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V
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ENVIRONMENTAL PROTECTION AGENCY
CONTENTS OF CHAPTERS
OCCUPATIONAL SAFETY AND HEALTH MANUAL
MANUAL
OCCUPATIONAL
SAFETY AND HEALTH
CHAPTER
TITLES
CHAPTER
NUMBERS
POLICY AND RESPONSIBILITIES 1
SAFETY AND HEALTH PROGRAM ACTIVITIES 2
ACCIDENT REPORTING 3
INSPECTIONS AND ABATEMENTS (RESERVED) 4
SAFETY AND HEALTH COMMITTEES (RESERVED) 5
STANDARDS (RESERVED) 6
TRAINING (RESERVED) 7
TN 3 (1-8-76)
ORIGINATOR: PM-215
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ENVIRONMENTAL PROTECTION AGENCY
CHAPTER 1 - POLICY AND RESPONSIBILITIES
TABLE OF CONTENTS
MANUAL
OCCUPATIONAL
SAFETY AND HEALTH
PARAGRAPH
TITLES
PARAGRAPH
NUMBERS
Purpose 1
Policy 2
Background ^. 3
Objective 4
Responsibilities 5
TN 3 (1-8-76)
ORIGINATOR: PM-215
CHAP 1
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ENVIRONMENTAL PROTECTION AGENCY
CHAPTER 1
POLICY AND RESPONSIBILITIES
MANUAL
OCCUPATIONAL
SAFETY AND HEALTH
1. PURPOSE. This Manual establishes policy, responsibilities, and
procedures for the conduct of the Agency safety and health program.
2> POLICY. It is the policy of the Environmental Protection Agency
to administer its programs in a manner that assures adequate protection
of its employees, property, and those for whom it has a responsibility.
Every manager, supervisor, and employee is responsible for identifying
risks, hazards, or unsafe situations or practices and for taking steps
to assure adequate safety in the activities under his supervision.
3. BACKGROUND. Executive Order 11807, Section 2, requires the head
of each Federal agency, after consultation with representatives of the
employees of the agency, to establish and maintain an occupational
safety and health program meeting the requirements of Section 19(a) of
the Occupational Safety and Health Act pf 1970 and 5 U.S.C. 7902(c)(l).
The head of the agency in compliance with Executive Order 11807 will:
a. Designate or appoint, to be responsible for the management and
administration of the agency occupational safety and health program,
an agency official with sufficient authority to represent effectively
the interest and support of the agency head.
b. Establish an occupational safety and health management infor-
mation system, which shall include the'maintenance of records of
occupational accidents, injuries, illnesses and their causes, and the
compilation and transmittal of reports to the Department of Labor
pursuant to Section 3 of Executive Order 11807.
c. Establish procedures for the adoption of agency occupational
safety and health standards consistent with the standards promulgated
by the Secretary, Department of Labor (thereafter referred to as the
Secretary) pursuant to Section 6 of the Act; assure prompt attention
to reports by employees or others of unsafe or unhealthful working
conditions; assure periodic inspections of agency workplaces by
personnel with sufficient technical competence to recognize unsafe
and unhealthful working conditions in such workplaces; and assure
prompt abatement of unsafe or unhealthful working conditions, including
those involving facilities and/or equipment furnished by another
Government agency, informing the Secretary of significant difficulties
encountered in this regard.
TN 3 (1-8-76) CHAP 1
3RIGINATOR: PM-215 ]_ PAR ]_
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OCCUPATIONAL
SAFETY AND HEALTH
MANUAL
CHAPTER 1 I
POLICY AND RESPONSIBILITIES
d. Provide adequate safety and health training for officials
at the different management levels, including supervisory employees,
employees responsible for conducting occupational safety and health
inspections, and other employees. Such training shall include dissemi-
nation of information concerning the operation of the agency occupa-
tional safety and health program and the means by which each such
person may participate and assist in the operation of that program.
e. Submit to the Secretary on an annual basis a report containing
such information as the Secretary shall prescribe.
f. Cooperate with and assist the Secretary in the performance of
his duties under Section 19 of the Act and Section 3 of Executive
Order 11807.
g. Observe the guidelines published by the Secretary pursuant
to Section 3 of Executive Order 11807, giving due consideration to
the mission, size and organization of the agency.
An interpretation of the requirements of Executive Order 11807 is
contained in 29 CFR 1960, "Safety and Health Provisions for Federal
Employees."
4. OBJECTIVE. The objective of the safety and health program is to
provide safe and healthful working conditions for all employees
through:
a. Control of causes of injuries and occupational illnesses;
b. Control of damage to property;
c. Protection of Agency programs; and
d. Maintenance of adequate data for corrective actions.
5. RESPONSIBILITIES.
a> Program Management and Audit.
(1) Administrator. The Administrator is responsible for
establishment and maintenance of the EPA Safety and Health Program.
CHAP 1 2 TN 3
PAR 3 1-8-76
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MANUAL
CHAPTER 1
POLICY AND RESPONSIBILITIES OCCUPATIONAL
SAFETY AND HEALTH
(2) Assistant Administrator for Planning and Management. The
Assistant Administrator for Planning and Management is responsible as
the Designated Safety and Health Official for the development and
conduct of the program and approval of safety and health policy,
standards, and regulations.
(3) Chief, Occupational Safety and Health Staff, Facilities
and Support Services Division. The Chief, Occupational Safety and
Health Staff is responsible as the designated Agency Safety and Health
Officer for the management, direction, and audit of the program and
the development of policy, standards, and regulations.
b. Program Implementation.
(1) Executive Officer, Office of the Administrator. The
Executive Officer, Office of the Administrator, is responsible for
the implementation of the EPA Safety and Health Program within the
Office of the Administrator.
(2) Assistant Administrators and Regional Administrators.
Assistant Administrators and Regional Administrators or a designee
with sufficient authority to implement the safety and health program
are responsible for implementation of the program.
(3) Regional and Facility Safety Officers. Regional and
Facility Safety Officers are personnel designated by the Regional
Administrator or Officer-in-Charge of a Reporting Unit. They are
responsible to assist their Regional Administrator or Officer-in-Charge
of their Reporting Unit for developing, organizing, directing, and
evaluating the safety and health program and for coordinating illness
and injury reporting and recordkeeping requirements; analyzing accidents
and injuries for prevention and control; and providing technical advice
to local officials in the implementation of program standards and policy.
TN 3 3 CHAP 1
1-8-76 PAR 5
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ENVIRONMENTAL PROTECTION AGENCY
CHAPTER 2 - SAFETY AND HEALTH PROGRAM
ACTIVITIES
TABLE OF CONTENTS
MANUAL
OCCUPATIONAL
SAFETY AND HEALTH
PARAGRAPH
TITLES
PARAGRAPH
NUMBERS
General 1
Safety and Health Report 2
Promotional Activities 3
TN 3 (1-8-76)
ORIGINATOR: PM-215
CHAP 2
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ENVIRONMENTAL PROTECTION AGENCY
CHAPTER 2
SAFETY AND HEALTH PROGRAM ACTIVITIES
MANUAL
OCCUPATIONAL
SAFETY AND HEALTH
1. GENERAL. Section 19(a)(5) of Public Law 91-596, December 29, 1970,
Occupational Safety and Health Act of 1970, requires the Administrator
to submit an annual report to the Secretary of Labor with respect to
occupational accidents and injuries and the Agency's safety and health
program. This report will be compiled by the Agency Safety and Health
Officer from data submitted to him from Officers-in-Charge of
Reporting Units.
2. SAFETY AND HEALTH REPORT. Each Officer-in-Charge of a Reporting
Unit will submit to the Agency Safety and Health Officer by February
15 of each year a comprehensive narrative Safety and Health Report
for the previous calendar year. The report must include the following:
a. Program activities for the past year (summarized);
b. Promotional materials that have been obtained and distributed
in support of Agency safety goals;
c. Accident and injury statistics (obtained from Annual Summary
Report of Federal Occupational Injuries and Illnesses, OSHA Form No.
102F, and Annual Summary Report of Federal Occupational Accidents,
OSHA Form No. 102FF);
d. OSHA (Occupational Safety and Health Administration, USDL)
standards compliance;
e. EPA standards compliance;
f. Safety Inspections conducted ("in-house");
g. Current special programs conducted;
h. Safety conferences held;
i. Safety communications; and
j. New program development.
An information copy of the above report must be submitted to the
Reviewing Authority and a copy should be retained at the Reporting
Unit.
TN 3 (1-8-76) CHAP 2
ORIGINATOR: PM-215 1 PAR 1
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OCCUPATIONAL
SAFETY AND HEALTH
MANUAL
CHAPTER 2
SAFETY AND HEALTH PROGRAM ACTIVITIES
3. PROMOTIONAL ACTIVITIES.
a. Each Assistant Administrator and Regional Administrator is
responsible for assuring the conduct of an active and innovative
safety and health promotional program at Reporting Units under his
jurisdiction. The conduct of the promotional program within the
Office of the Administrator will tTe the responsibility of the Executive
Officer.
b. The Agency Safety and Health Officer will periodically forward
to the Officer-in-Charge of each Reporting Unit material pertaining
to Government-wide promotional programs sponsored by the Office of
Federal Agency Programs, U.S. Department of Labor, and activities
required in conjunction with the observation of National Fire Preven-
tion Week. Implementation action on these mandatory National
promotional programs is the responsibility of the Officer-in-Charge
of the Reporting Unit.
c. The Occupational Safety and Health staff will offer
advice and assistance and will periodically assess the effectiveness
of safety and health promotional programs through field visits and
program evaluations. Evaluation reports of promotional programs will
be submitted to the Agency Designated Safety and Health Official.
d. Officers-in-Charge of Reporting Units are encouraged to
purchase safety and health promotional items such as posters, booklets,
pamphlets, and audio-visual materials from commercial and Governmental
sources which specialize in such items. The following list of potential
sources is furnished for informational purposes only. It does not
include all commercial firms marketing promotional materials and
commercial firms listed must not be considered mandatory sources of
supply:
- National Safety Council, 425 North Michigan Avenue,
Chicago, Illinois 60611
- National Fire Protection Association, 470 Atlantic Avenue,
Boston, Massachusetts 02210
- Dray Publications Inc., Deerfield, Mass. 01342
- Channing L. Bete Co. Inc., 45 Federal Street,
Greenfield, Mass. 01301
CHAFT" ~~ ~"~2~ ' ' TN^
PAR 3 L_8_76
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MANUAL
CHAPTER 2
SAFETY AND HEALTH PROGRAM ACTIVITIES
OCCUPATIONAL
SAFETY AND HEALTH
- U.S. Department of Labor, Office of Information,
Occupational Safety and Health Administration,
200 Constitution Avenue, N.W., Washington, D.C. 20210
- General Services Administration, National Archives and
Records Service, National Audio Visual Center,
Washington, D.C. 20409
- American Medical Association, Department of Occupational
Health, Division of Scientifc Activities,
535 North Dearborn Street
Chicago, Illinois 60610
- Local Fire Departments
- Local Municipal Offices of Public Safety
- Local Law Enforcement Agencies
- Local Safety Councils
- State, County, and Local Safety and Health Officials
Information regarding additional source material on specialized
subjects is available from the EPA Occupational Safety and Health
Staff (PM-215).
TN 3 3 CHAP 2
1-8-76 PAE 3
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ENVIRONMENTAL PROTECTION AGENCY
CHAPTER 3 - ACCIDENT REPORTING
TABLE OF CONTENTS
MANUAL
OCCUPATIONAL
SAFETY AND HEALTH
PARAGRAPH
TITLES
PARAGRAPH
NUMBERS
Policy 1
Definitions 2
Procedures 3
Related Reports 4
U.S. Department of Labor Reporting Requirements „ . 5
References 6
Figure 3-1. Supervisor's Report of Accident
Standard Form 92
Figure 3-2. Safety Officer's Analysis of Accident
EPA Form 1440-7
Figure 3-3. OSHA Forms 102F and 102FF
Appendix 3-A. Instructions and Coding for Safety
Officer's Analysis of Accident
(EPA Form 1440-7)
Appendix 3-B. Instructions for Completing Log of
Federal Occupational Injuries and
Illnesses (OSHA Form 100F)
Appendix 3-C. List of Reporting Units, Reviewing
Authorities, and Officers-in-Charge
of Reporting Units
TN 3 (1-8-76)
ORIGINATOR: PM-215
CHAP 3
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MANUAL
CHAPTER 3
ACCIDENT REPORTING
OCCUPATIONAL
SAFETY AND HEALTH
1. POLICY. All job-connected accidents should be reported in
accordance with procedures outlined in this Chapter. Employees will
furnish full information about the accident to complete an accurate
report.
2. DEFINITIONS.
a. An accident is defined as any job-connected incident involving
Agency personnel, property, or operations, which result in personal
injury, vehicle collison, fire, potential claim against the Govern-
ment, or property damage of $100.00 or more, or any incident having the
potential to cause death or serious injury.
b. A job-connected accident requiring immediate reporting is
defined as follows:
(1) A fatality or disabling injury involving loss of use of
a principal part of the body; or an apparently total disability which
prevents the injured employee from returning to his normal job; or
the injury of three or more employees in a single accident requiring
hospitalization, regardless of cause or severity.
(2) Damage exceeding $10,000 to EPA leased or controlled
property.
(3) An injury requiring medical attention, or a fatality, to
non-EPA personnel, stemming from EPA operations; or damage exceeding
$10,000 done to non-EPA property and arising from Agency operations.
(4) Any accident with the potential for permanent injury
or death.
3. PROCEDURES.
a. Supervisors will investigate and report within 48 hours all
job-connected accidents on 'SF 92, Supervisor's Report of Accident,
Figure 3-1. Instructions for completing this form are on the reverse
side of the form. The original of the SF 92 shall be forwarded to
the Agency Safety and Health Officer via the following organizational
elements:
TN 3 1 CHAP 3
1-8-76 PAR 1
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MANUAL
CHAPTER 3
OCCUPATIONAL
SAFETY AND HEALTH
ACCIDENT REPORTING
(1) Field Operations. The Supervisor will forward the report
directly to the Agency Safety and Health Officer. A copy shall be
sent to (1) the Officer in Charge of the Reporting Unit, (2) the
Regional and/or Facility Safety Officers, and (3) the Agency and local
Tort Claims Officer.
(2) Washington Metropolitan Area Headquarters Locations. The
Supervisor will forward the report directly to the Agency Safety
and Health Officer. A copy shall be sent to the Agency Tort Claims
Officer.
b. Upon receipt of the SF 92, the Regional or Facility Safety
Officer shall complete a Safety Officer's Analysis of'Accident, EPA
Form 1440-7, Figure 3-2. This form shall be completed according to
guidelines contained in "instructions and Coding for Safety Officer's
Analysis of Accident," EPA Form 1440-7, Appendix 3-A. The original
shall be sent to the Agency Safety and Health Officer (PM-215) within
ten calendar days after the accident and a copy retained by the
Regional pr Facility Safety Officer. A copy shall also be submitted
to the Officer-in-Charge of the Reporting Unit. These forms and
instructions represent a Safety Management System as required under
Executive Order 11807.
c. The Agency Safety and Health Officer will be notified by the
supervisor of a job-connected accident requiring immediate reporting
as quickly as possible by telephone, teletype, etc. However, notifi-
cation is not required if a fatality clearly was unrelated to perform-
ance of work and occurred while an individual was not on official duty.
If there is any doubt, notification and reasons for doubt will be
given. The following information is to be furnished:
(1) Name(s) of injured person{s);
(2) Cause of accident;
(3) Location and brief circumstances;
(4) Name(s) and address(es) of the next of kin for a work-
connected fatality;
(5) Type and extent of property damage;
(6) Present status (i.e., rescue efforts underway, preliminary
medical diagnosis, control of fire, etc.); and
CHAP 3 2 TN3
PAR 3 1-8-76
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MANUAL
CHAPTER 3
ACCIDENT REPORTING OCCUPATIONAL
SAFETY AND HEALTH
(7) Telephone number where additional information may be
obtained, if required.
d. In case of a fatality, the Agency Safety and Health Officer
will forward to the Deputy Assistant Administrator for Administration
pertinent information along with a proposed telegram of sympathy from
the Administrator to the surviving spouse, parent, or other next of
kin.
4. RELATED REPORTS. The submission of SF 92 does not relieve
supervisors of the responsibility for other reports required under
regulations, including:
a. State and local police reports;
b. SF 91, Report of Motor Vehicle Accident;
c. SF 91A, Investigation Report of Motor Vehicle Accident;
d. Coast Guard Form CG 3865, Boating Accident Report; and •
e. NTSB 6120.1, Pilot-Operator Aircraft Accident Report.
5. U.S. DEPARTMENT OF LABOR REPORTING AND RECORDKEEPING REQUIREMENTS.
a. Title 29, Chapter XVII, Part 1960 of the Code of Federal
Regulations imposes special accident, injury, and illness reporting
requirements upon Federal Agencies. Under these regulations, EPA is
required to furnish the Department of Labor with a quarterly and
annual summary of all occupational injuries, illnesses, and accidents
utilizing OSHA Forms 102F and 102FF, Figure 3-3. Instructions for com-
pleting these forms are contained on the forms themselves. Separate
OSHA Forms 102F and 102FF are required for civilian personnel and
military (non-combat) personnel (i.e., PHS Commissioned Corps). EPA is
also required to maintain a record or log of all recordable occupational
injuries and illnesses at each Reporting Unit. Where both civilian and
noncivilian employees are employed at a single reporting unit, separate
records or logs shall be maintained for each category. OSHA Form 100F
shall be used for this prupose. Instructions for completing OSHA Form
100F are in Appendix 3-B.
CHAP 3
PAR 3
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MANUAL
CHAPTER 3
OCCUPATIONAL ACCIDENT REPORTING
SAFETY AND HEALTH
b. OSHA Forms 102F and 102FF will be forwarded by the Agency
Safety and Health Officer to each "Officer-in-Charge of a reporting
unit" via the reviewing authority on a quarterly and calendar year
basis. Completed reports must be sent back to the reviewing authority
for summarization and a final^consolidated report must be sent to the
Agency Safety and Health Officer from, the Reviewing Authority no later
than thirty days after the close of each quarter. An annual report
shall be forwarded no later than thirty days after the close of the
calendar year. For reporting and recordkeeping purposes, the senior
official at a geographic location is the "Officer-in-Charge of a
Reporting Unit." In locations where several separate organizations
or programs are located in a given geographical location, the senior
official in charge of each organization or program is designated an
"Officer-in-Charge of a Reporting Unit" and his program within a given
geographical location constitutes a separate Reporting Unit. Each
"Officer-in-Charge of a Reporting Unit" is responsible for compiling
occupational illness, injury, and accident data from his establishment
or program and forwarding the completed OSHA Form 102F and 102FF to
the Reviewing Authority.
c. Within six working days after receiving information of a
recordable occupational injury or illness, appropriate information con-
cerning such injury or illness shall be entered on OSHA Form 100F, Log
of Federal Occupational Injuries and Illnesses by the Officer-in-Charge
of a Reporting Unit. This recordkeeping form is to be maintained at
the Reporting Unit in a current status.
d. A list of Reporting Units, Reviewing Authorities, and
"Officers-in-Charge of Reporting Units" is contained in Appendix 3-B.
For reporting purposes, Assistant Administrators and Regional Admin-
istrators are designated "Reviewing Authorities." Each reviewing
authority is responsible for obtaining all OSHA Forms 102F and 102FF
from his subordinate "Officer(s)-in-Charge of a Reporting Unit;"
consolidating the information on these forms into summarized OSHA Forms
102F and 102FF encompassing civilian and military (noncombat) personnel,
and forwarding the two summaried forms with original Reporting Unit
OSHA Forms 102F and 102FF attached to the Agency Safety and Health
Officer on a quarterly and annual basis.
CHAP 3 4 . TN 3
PAR 5 1-8-76
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CHAPTER 3
ACCIDENT REPORTING
MANUAL
OCCUPATIONAL
SAFETY AND HEALTH
6. REFERENCES. The Office of Federal Employees' Compensation
administering the Federal Employees' Compensation Act, imposes
occupational health and injury-related reporting requirements upon the
employee, the supervisor, and others. Complete information is available
in Chapter 810 of the Federal Personnel Manual. Pamphlets BEC-11,
"When Injured at Work," and BEC-550, "Work Injury Benefits for Federal
Employees," available through the local personnel office, are also
useful.
TN 3
1-8-76
CHAP 3
PAR 6
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CHAPTER 3
ACCIDENT REPORTING
OCCUPATIONAL SAFETY AND HEALTH
PRO^LGA^DDE'™*^ SUPERVISOR'S REPORT OF ACCIDENT
T^uuRA^WEV6)" DO NOT USE FOR MOTOR VEHICLE OR AIRCRAFT ACCIDENT
•2-102
(See Instructions on Back. Use Additional Sheets if Necessary)
ta
ili
ee
Sactlon II
WHEN, WHERE, HOW, AND WHY ACCIDENT OCCURRED
AND CORRECTIVE ACTION
SacHm III
CONSEQUENCES AND RELATED DATA
UJ
1WI
>*i
_ uj 2
la. TO: (Appropriate Headquarters)
2. ACCIDENT OCCURRED IN
b. FROM: (Reporting Dept., etc., and location- Include town and State or foreign country) GOVERNMENT CONTRACTOR
OPERATION OPERATION
3. DATE OF ACCIDENT 4. TIME 5. EXACT LOCATION OF ACCIDENT
6. DESCRIPTION BY INJURED PERSON: IF PROPERTY DAMAGE ONLY. BY PERSONS MOST CLOSELY ASSOCIATED WITH ACCIDENT (Tell the complete
story of what happened; no signature required.)
7. DESCRIPTION BY RESPONSIBLE SUPERVISOR— CIVILIAN OR MILITARY (What led up to the accident, how did accident actually happen?
8. WHAT ACTUALLY HAS BEEN DONE TO CORRECT CONDITIONS CAUSING THE ACCIDENT?
9. WHAT REMAINS TO BE DONE TO CORRECT SUCH CONDITIONS AND WHYT
10a- INJURY TO: (Check one) lOb. PROBABLE DISABILITY 10C' ESTIMATED DAMAGE TO PROPERTY OR
REPORTING AGENCY (Check one) EQUIPMENT {Fill in one or more)
(1) MILITARY (1) CIVILIAN (3) CONTRACTOR (l) DEATH (*) TEMPORARY (l) REPORTING AGENCY f
(Z) CONTRACTOR* (
OTHER (2) PERMANENT (S) TEMPORARY (3) OTHER FEDERAL f
(4) OTHER FEDERAL AGENCY (S) NONFEDERAL PERSON
(3) PERMANENT (6) FIRST AID (4) NONFEDERAL S
* Contractor of reporting agency
II. DESCRIPTION OF PROPERTY OR EQUIPMENT DAMAGED
12. OWNERSHIP OF PROPERTY OR EQUIPMENT DAMAGED (Name and home address)
13. NAME AND HOME ADDRESS OF INJURED 14. SEX 16. BADGE OR SERVICE NO.
15. AGE
17. REGULAR OCCUPATION OF INJURED 18. OFFICIAL ASSIGNMENT AT TIME OF ACCIDENT
(9. NATURE OF INJURY AND PART OF BODY INVOLVED 20. DATE NJURED STOPPED WORK 21. DATE INJURED RETURNED TO
WORK
22. NAMES AND ADDRESSES OF WITNESSES
23. DATE TITLE {Civilian or military) SIGNATURE OF SUPERVISOR
24. COMMENTS ON ADEQUACY OF CORRECTIVE ACTION TAKEN. OR PLANNED. NCtUOING PROGRESS ON PENDING ACTIONS
25. DATE TITLE (Civil, an or military) SIGNATURE OF REVIEWING OFFICIAL
DO NOT
USE
CODE
TN 3
1-8-76 Figure 3-1 Supervisor's Report of Accident Standard Form 92
(Part 1 of 2)
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INSTRUCTIONS
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SCOPE: Form applies to every accident, except motor vehicle and aircraft, arising out of the opera-
tion of a Federal Department or Establishment which results in injury to a person, or damage to propt-rty
This form may be used similarly for operations performed by contractors under the jurisdiction of the
Importing department, item Ib. It is not a substitute for any report to the Bureau of Employees' Compen-
sation, but the reverse side of Form C. A. 1 of that Bureau should hereafter not be used,
SECTION I
Item t. GOVERNMENT OPERATION.—Work
performed by Government forces.
CONTRACTOR OPERATION.—Operation per-
formed by a contractor's forces under
jurisdiction of the reporting department
named in item Ib.
SECTION II
Item S. Date of accident.
Item 4. -Hour of day or military time.
Item S. 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, lOa. Injury to—Self-explanatory.
REPORTING AGENCY.—Department or es-
tablishment indicated in item Ib.
Item lOb. (1) DEATH.—Self-explanatory.
(2) PERMANENT TOTAL. — An injury
which permanently and totally inca-
pacitates a person from following any
gainful occupation.
(8) PERMANENT PARTIAL.—An injury
which results in the loss of any mem-
ber 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 in-
jured person unable to perform a
regularly established job on any day.
or shift subsequent to the day of in-
jury (including Saturdays, Sundays,
and days off).
JSSSSSffliJV SUPERVISOR'S REPORT OF ACCIDENT
^•cu^t'i'l?!0."1 DO HOT VIE fOK MOTOR VEHICLE 01 IIFCIAFT tCCIDEST
-1 Chief of Ehglnsers, »«shlngton 25, D. C. - )
| S S B FROM [•.,*.>.„< B.,< .1C . .fld IK*...J,-r«clud. •.-„ .nd SIX. ., «-*,!,. *•
S IDept. of Any, Corps of bigineers, Ohio River Div.
Huntlngte-n District. Bwitlnrton. «. ft.
,..„„..«,., rri; rrnsi..-.,. ^..buuoa v-uu 6t stfeia
Oet-.B^WUT I i P... "
™ * "o^"f^*l'fcVD^n,""™1.,l'n7rDu7"*,
u While aalrtDg discharge wajuretMnt, I was lowitrlng sounding weight to
Z botto« of riv«r by use of real and crank. Puboerged log hit cable, knoek-
jjj« ing^ crank out. of hand. CrarJc handle struck nose and forehead.
* J JE Discharge aeasureaents wr« being m«de during hlgh*at«r. Due to fact that
j oS th« brak« on the re«l vaa dafectiva, the'bounding wilght was b«ing lowitrtd
3 g by %aa of crank. Nurmail/ the sounding weight is lomrad bj using brake
*^ only. Crank should b« replscad with hand-w!»el.
> Defeetiv* brake has ton npsdrcd and hand-wheel ordered.
* Get approval for purchase of hand-wheel to replace crank. Such purchase
requires approral by h»*d of plant section.
W..ILIT, I
_ _ ioo7oo
I •••'••
a
5
IS Loss of sounding weight and diachargs measurenent device.
Z Corps of bigineerj. Hunting-ton District, Huntington, W. Va.
| JohrTD.''DM,"£<><» "ialn St., Huntington, ».7». ,; Fi—JJ 1 ""»o°n™"" "°
Engineer Aide ] Stream gauging
V»HiBiLl|°" "i contusion, on nose snd| ctet. 9. 19117 I o?". 11. 191.7
•= 5 Ralph H. Black 9097 South'st., Huntlnuton, W. Ta.
i«
* Jamas E. Brown 8099 Tenth St., Huntington, W. Ta.
S*g| cct.'ll, U7 !5tr«'a.'o"au'gln'g"s'ectlon' I
£ Instructions have bean issued that brake is to be used In lowering sounding
j£S mights with crank disengaged In all cases. Purchase of hajid^whej.* to
i E S replace all cranks has been approved. •
5 10-M-li7 I Chief, fcgineVrlnc Dlv. ""u£Z£
PREPARATION: Answers must be given to all items on the form except as noted below: Accidents
resulting in injury only, require answers to fill items except lOc, 11. and 12; accidents resulting in property
damige only, retire answers to all items except lOa. lOb, and 13 through 21 inclusive : acci-iema resuiune
in ir.jury ami property damage require answers to all items. If a single accident involves injury to more"
thnn one perFon or damage to the property of more tha-i one owner, a separate Form 92 is to be filled O'^t
for (ach injured person or each owner of damaged property.
SECTION III (Continued)
(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 per-
forming another regularly estab-
lished job.
(6) FIRST AID (Medical Treatment
Case).—An injury which requires
medical treatment or.ly and does not
result in loss of time. •
Item lOc. Property or equipment includes
material. Give closest estimate possible
oi damage; do not state "unknown," "un-
determined." Each loss must be explain-
ed in item 11.
(1) REPORTING AGENCY.—Department or
establishment indicated in item Ib.
Item 11. Include damage to material..
Item 18. Work or duty assignment by su-
pervisor at time of accident.
Item 20. The date of the first day (subse-
quent to the date skou'n in item 3} when
the injured commenced losing time.
Item 21. The day injured returned to work:
report shall not be delayed beyond the enu
of calendar month for completion of this
SECTION IV
Item M. Should be "eye witnesses" if avail-
able; if not, first persons hearing of acci-
dent from injured person or other sources.
SECTION V
Item 23. Supervisor responsible for the in-
formation in items 3-22, inclusive.
SECTION VI
Item 34. The designation of the reviewing
official is the responsibility of the depart
ment or establishment but should he an
operating official above the level of the
supervisor indicated in item 23.
I U>
--a
REMARKS:
USE ADDITIONAL PLAIN SHEETS OF PAPER If NECESSARY
U.S. GPO: 1974—5B7-«17
-------
CHAPTER 3
ACCIDENT REPORTING
OCCUPATIONAL SAFETY AND HEALTH
SAFETY OFFICER'S ANALYSIS OF ACCIDENT
(Refer to Occupational Safety and Health Manual)
REPORT NO.
SECTION A _ IDENTITY DATA
1. ORGANIZATIONAL CODE
£ as(
3. STATI-: IN WHICH ACCIDENT
OCCURRED
2. REPORTING STATION (Hume and address
Z/P Cotfc)
4. DATE Of ACCIDENT
8. EMPLOYMENT STATUS
Last No.
I
_irnr
5.. NEAfttxST HOUR 2^-26
OF ACCIDENT
ID, USUAL ASSIGNMENT
52-53
11. ACTUAL AS5GMT
9. CSC i.ast (vo. —i
46 oc'cu- ,,.,.5, f
1. PERMANENT i'. TEMPORARY ! RATION [ I ] —r 1 1 M
3. CONTRACTOR <1. FUULIC CODE
8. OTHER (Explain! I
12. NUMBER OF MOUTHS AT 13. AGE OF EMPLOYEE j 14. SEX IS. GRADE
THIS TYPE WORK r
56-58 59-60 bl 62-65
:-[ I.MALE
2. FEMALE ( |
16. IDENTIFY PROPERTY/EQUIPMENT 17. PROPERTY/EQU IPME NT OWNERSHIP IB. AGIi OF PROPERTY/
DAMAGED (Give numi, morfcl no., size,
make, type, eti-.l "• NONE b. GSA MOTOR POOL
1. EPA e. PRIVATELY OWNED
2. OTHER FED. 7. O T H E R (Explain) 71,-
3. CONTRACTOR '1-7.-
L4. EMPLOYEE-OWN
II ON OFFICIAL BU
SECTION B - MEDICAL
19. NATURE OF INJURY OR ILLNESS 20. PART OK BODY INJURED
73-74 75-76
'21. SE~yE"RTTY~dF INjijViY 22. CA FORMSl>R"ETFrAfiFD"A~N D | 23. TYPE OF ACCIDENT
PROPERLY ROUTED
0. NO INJURY INVOLVED
1. FIRST AID ATTENTION ONLY "'' YF-S °- NO
2. MEDIC AL ATTEN TIOIJ (TVoM-disaii//.-)^) 77 73 79
. DISABLING INJURY (T-.n.pnmry)
4. DISABLING INJURY (/-'e^ManenO
5. FATAL
. J__l
24. LOST TIME* OTHER DATA | MONTH DAY YEAR | NUMBER OF LOST Last No.
WORK DAYS AND OTHER
A. STOPPED WORK j , JDATA ^_^.
F>. r! E T u R N E D W O R K . I
C. D E A 1 1 i O A T r _| [ [ I
SECTl6N"c~^N/TRRATT\'f:~FESCRIPTIOM OP ACCIDENT
25, (Incluite ivflt,, iv/wi, n-herc, H-hrn and t-ov.:) NOTE; CONDENSE STORY HEriE AND CONTINUE ON SEPARATE SHEET FOR FULL
DETAILS.
SECTJO_r4_D-FACILITY AND/OF! IKEGjONALJAFETY OFFICER'S OPINION .
26. IN TERMS OF POLICY OR IMPROVEMENT, I RECOMMEND THE FOLLOWING:
E PA Form 14>lO-7 (1-76) REPLACES LPA FORM »4.10-1 DIS rnt BUTION: i. FACILITY SAFETY OFFICER
WHICH IS OBSOLETE. 2. REGIONAL S A F E T Y O !- •- I C E R (It arjpli, -,,l,lf )
3. AGENCY SAFETY AND 1-lEALThl Of-FICr.b1
4. O F Fl C ER-IN-C HAR G f OF REPORTING UNiT
TN 3
1 8 7fi /« Figure 3-2. Safety Officer's Analysis of Accident EPA Form 1440-7
6 * 10 rpurt 1 of 2)
-------
CHAPTER 3
OCCUPATIONAL SAFETY AND HEALTH
ACCIDENT BEPnRTTNR
SECTION E - AGENCY OF ACCIDENT
27. DIRECT AGENT 28. CONTRIBUTING AGENT B8 9 1 '
SECTION F - WORKING ENVIRONMENT
30. NATURAL ENVIRON- 96-97 31. POLICY AND PLANNING 98-99
SECTION C - STAFF SERVICES
33. PERSONNEL RELATED FACTOR 103-10^ -"'• FACILITIES RE
_ . rn~
SECTION H - COST DATA
9. DEFECT OF AGENT
94-9S
92-93
>2. OPERATIONAL PROCEDURES 100-10?
TTT
LATED FACTOR 106-108
TT
35. ESTIMATED DAMAGE TO GOVERNMENT LnsI Na. y | 36. ESTIMATES. DAMAGE TO NON- Lasr No. " f
109-113 "n>y>
SECTION 1 -CORRECTIVE ACTION
37. LOCAL CORRECTIVE ACTION 1 AKEN OR PLANNED (II yes, bristly efe.ictiha below) 1
PROPERTY (Uollart 1
,1,1,8 | | | | !
YKS 0. NO 1
,19 1
DESCRIPTION OF ACTION
DATE TAKEN/PLANNED 1 NAME AND TITLE OF RESPONSIBLE PERSON
38. AGENCY (or Kcgronut) ASSISTANCE r
-------
CHAPTER 3
ACCIDENT REPORTING
OCCUPATIONAL SAFETY AND HEALTH
OSHA No.
102l;and 102FF
1976 FEDERAL OCCUPATIONAL INJURIES AND ILLNESSES SURVEY
(QUARTERLY SURVEY)
P.O. Box 2527
Attention: OMDS-OSHA
U.S. Department of Labor
Main Post Office
Washington, D.C. 20013
r
~i
Report for the agency
identified to the right
L
J
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 Property Damage Incidents." 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 booklet "Recordkecping and Reporting Guidelines for Federal Agencies" for additional information concerning
Federal Agency responsibilities under the Williams-Steiger Occupational Safety and Health Act of 1970.
Report prepared by:
Title:
Date:
Phone:
Comments:
Please turn page and complete 102F and 102FF forms
TN 3
1-8-76
Figure 3-31 OSHA Forms 102F and 102FF
(Part 1 of 4)
-------
CHAPTER 3
OCCUPATIONAL SAFETY AND HEALTH Ar.r.IDF.NT REPORTING
INSTRUCTIONS FOR REPORT PREPARATION - FORM OSHA NO. 102F
Insert a check-mark (V) in the appropriate s.quare 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,
03 - 31 - 76 means the period January 1 - March 31, 1976.
INSTRUCTIONS for completing this form: All entries must be summarized from the log (OSHA No. 1 OOF) or its equivalent. Before pre-
paring this summary, review tlie log to be sure that entries are correct and each case is included in only one of the following classes: deaths
(date in column 8), lost workday cases (check in column 9) or nonfatal cases without lost workdays (check in column 10). If an employee's
loss of workdays is continuing at the time the annual summary is being made, estimate the number of future workdays he will lose and add
that estimate to the workdays he has already lost and include this total in the annual summary. No further entries arc. to be made with re-
spect to such cases in the next year's annual summary. Quarterly summaries should only reflect actual lost workdays for that reporting
quarter.
Occupational injuries and the seven categories of occupational illnesses are to be summarized separately. Identify each case by the code in
column 7 of the log of occupational injuries and illnesses.
The Summary Form OSHA No. 102F should be completed as follows:
A. (Code 10) Occupational Injuries (identified by Code 10 in Column 7 of the OSHA No. 100F Log). Record the following on the line
designated by Code 10 on the OSHA No. 102F:
Column 1. Total injury cases. Count the number of times Code 10 appears in Column 7 of the OSHA No. 100F log. Enter the total
oTthTTcouiU under Column 1 of the OSHA No. 102F.
Column 2. Tota[deaths. For all Code 10 entries, count the number of times a date appears in Column 8 of the OSHA No. 100F Log.
Enterthelotal of this count under Column 2 of the OSHA No. 102F. ,
Column 3. Total Lost Workday Cases. For all code 10 entries, count the number of times a check-mark (V) appears in Column 9 of
the OSHA No.'itS.F Log. Enter the total of this count under Column 3 of the OSHA No. I02F.
Column 4. Total Cases Involving Days Away From Work. For all code 10 entries, count the number of times an entry (don't total
the numbers) appears in Column 9A of the OSHA No. 100F Log. Enter the total of this count under Column 4 of the
OSHA No. 102F.
Colunm 5. Total Days Away From Work. For all code 10 entries, add all the entries (total the numbers which appear in Column 9A
of the OSHA No. 100F Log. Enter the total of this addition under Column 5 of tt^OSHA No. 102F.
Column 6. Total Days of Restricted Work Activity. For ail code 10 entries, add all the entries (total the numbers which appear in
Column 9B of the OSHA No. 100F Log. Enter the total of this addition under Column 6 of the OSHA No. 102F.
Column 7. Total Nonfatal Injury Cases without Lost Workdays. For all code 10 entries, count the. number of limes a check-mark (\/)
appears in Column 10 of the OSHA No. 100F Log. Enter the total of this count under Column 7 of the OSHA No. 1_02F.
ColumnS. Total Injury Cases which Result in Termination of Employment or Permanent Job Transfers. For all code 10 entries,
count the number of times a check-mark (\7Tappcars m Column 11 of the OSHA No. 100F Log. Enter the total of this
count under Column 8 of the OSHA No. 102F.
CHECK: From the totals entered according to the instructions above, an easy check for accuracy can be made. Add the entries
under Columns 2, 3, and 7; and this total must equal tlie entry for Column 1. (Columns 2+3+7 = Column!).
B. (Codes 21 through 29) Occupational Illness Codes. Follow the procedure for A above for each illness code, entering the totals on the
appropriate line of this form.
C. (Code 30) Total - Occupational Illnesses. Add the entries for codes 2 1 through 29 in each column and enter totals on the line for
code 30.
D. (Code 31) Total - Occupational Illnesses and Injuries. Add the entries for codes 10 and 30 in each column and enter totals on the line
for code 31.
CHECK: If the summary has been made correctly, the entry in column 1 of the total line (code 31) of this form will equal tlie total
number of cases on the log.
E. (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 in-
clude their actual hours worked. Do not combine civilian and milit;-v man-hours worked. Please do NOT report man-days; all man-
days should be converted to man-hours by the reporting agency.
F. (Code 50) Average number of employees. Insert the average number of full and part-time employees during the repotting period. In-
clude all classes of employees (i.e., adminislrative, supervisory, clerical, professional, non-professional, technical, other related workers,
etc.). Do not combine civilian and military average number of employees.
G. (Code 51) If the average work week for the employees in your agency varies more or less than 25% of the normal work week, i.e., 40
hours, check the box for code 51; otherwise, luavc it blank. Examples: (aj employees worked so much overtime that the average work
week went from 40 hours per week to over 50 hours per week; (b) there are so many part-time employees in your agency that the
average work week dropped from 40 hours per week to less than 30 houis per week.
Figure 3-3. OSHA Forms 102F and 1Q2FF TN 3
(Part 2 of 4) 1-8-76
-------
CHAPTER 3
ACCIDENT REPORTING
OCCUPATIONAL SAFETY AND HEALTH
OSIIANo. 102F
SUMMARY REPORT OF FEDERAL OCCUPATIONAL INJURIES AND ILLNESSES
A. This is the separate summary report for:
A.I Civilian Personnel-
A.2 Military (Non-combat) Per
ionncl —I I
K Report Period Fnding Date
nonoan
Day
Year
INJURY AND ILLNESS
CATEGORY
CATEGORY
OCCUPATIONAL INJURIES
CvcupatiOfntl Skin Diseases
O or Disorder!
Dust Diseases of lha Lung*
P
A Respiratory Conditions Due
_ to Toxic Agents
Poisoning (Systemic Effect*
O Of Toxic Materials)
A Disorders Due to
L Physical Agents
I Disorders Associated
L With Repeated Trauma
N All Other Occupational
™ Illnesses
q TOTAL -OCCUPATIONAL
| ILLNESSES
S code 29)
TOTAL-OCCUPATIONAL
INJURIES AND ILLNESSES
(Sum of code 10 and code 30)
Total Man-hours worKed
by all employees
Average number of
employees
Average work w««J< for
all employees
c
O
D
E
10
21
22
23
24
26
29
30
31
40
50
51
TOTAL
CASES
Number of
Col. 7 of
the log.
U)
DEATHS
Number of
Co!. 8 of
t.le log.
(2)
LOST WORKDAY CASES
Total
Lost
Cases
Number of
Col. 9 of
' £3
Cases
Involving
Number of
Col. 9A of
(4)
Days
Sum of
Co|. 9A Of
(5)
Days of
Restricted
Sum of
Col. 9B of
(6)
NONFATAL
CASES
WITHOUT
LOST
WORKDAYS
Col. 10 of
m
TERMINA-
TIONSOR
PERMA-
NENT
TRANS.
FERS
Number of
Col. 11 of
trie log.
1
r .J _
(This Reporting Period)
(This Reporting Period)
D Check this box^ortly when average work week for all employees is (a) less than 30 hours or
(b) more than 50 hours per week.
TN 3
1-8-76
Figure 3-3. OS1IA Forms 102F and 102.FF
(Part 3 of 4)
-------
OCCUPATIONAL SAFETY AND HEALTH
CHAPTER 3
INSTRUCTIONS FOR REPORT PREPARATION- FORM OSHA NO. 102FF
A reportable occimational_nropcrty damage incident for OSHA Form No. 102FF is any accidental occurrence (a) in which Federal Govern-
ment property is involved and/or a Federal employee is involved while on official Government business and (b) where property damage (in-
cluding both Federal and private) results in a total of $100 or more.
The Summary Form OSHA No. 102FF shall be completed as follows:
A. A summary of occu;-aHpn^Ip£ojierty di am age in ciden ts which conform to the definition stated above shal! be separated and entered
under one of the categories listed below. Count the number of occurrences which fit into each category and record that total on the
line designated by Code 8.0 (Total Property Damage Incidents) of the OSHA No. 102FF.
1.1 ^OTenimen|_Autom(^bjlo Pro^j>ejJyJ)ajiia£^ljicide_m: Occurrence involving a car, bus, truck, or motorcycle which is (a) owned,
ieased, or rented by the Federal Government and (b) used for official Government business at the time of occurrence.
1.2 Private Automobile Property Damage Incident^: Occurrence involving a car, bus, truck, or motorcycle which is (a) not owned by
the Federal Government but is authorized by the Federal Government for travel and (b) used for official Government business at
the time of occurrence.
NOTE: When a single occupational property damage incident involves both a Government and private automobile, report as on£
incident under the column which reflects the responsibility for the occurrence.
2.0 Crane, Lift^E_tc.t Property Damage Incident: Occurrence involving construction, warehouse, supply room, or yard "Cranes,
Lifts, Etc." (as defined by the safety and health standards promulgated under Section 6 of the Occupational Safety and Health
Act of 1970) which is (a) operated by a Federal employee and (b) used for official Government business at the time of occur-
rence.
3.0 Marine Property Damage Incident: Occurrence involving a water-borne craft (motorized, non-motorized, steam, sail, towed, etc.)
which is capable of being used as a means of transportation on water, including special purpose floating structures not primarily
•designed for or used as a means of transportation on water.
4-0 AJrcraft Property Damage Incident: Occurrence involving airborne craft (powered, towed, or free flying).
5-0 property Damage iricidents^hertlian Vehicles: Occurrence involving Government and/or private material, equipment, or
machinery which is not classified as a vehicle. This includes accidental occurrences due to use or misuse of the material, equip-
ment, or machinery. Examples include; (a) dropping a typewriter which damages either the typewriter or the material that it
drops on or hits;(b) accidental bursting of a pipe which damages the nearby supplies; (c) falling material, equipment, or machinery
from a scaffold, shelf, or top of building.
6.0 Fire: Occurrence involving accidental burning or smoldering. This also includes damage caused as a result of (a) by-products of
such an occurrence (smoke, etc.) and (b) extinguishment or control of such an occurrence.
B. A summary of vehicle usage shall be recorded on the line designated by Code 9.0 on thj^QSHA No. 1Q2FF as follows:
'•1 Government Automobiles - loul number of miles agency owned, leased, or rented vehicles were driven for this i spoiling period.
1,2 private Automobiles- total number of miles an agency reimbursed its employees for authorized travel for this reporting period.
2.0, 3.0, 4.0 Total Hours Operated - total (approximate if exact records are not available) number of hours the agency vehicles were
operated for this reporting period.
enter the total of this addition under the appropriate category
D. A summary of tort claims (dollar amount) which result from the occupational property damage incidents other than breach of con-
tract shall be entered on the line designated by Code 10.0 of the OSHA No. 102FF under the category 7.0. Report only those tort
claims paid out for that reporting period, regardless of when the incident occurred.
NOTE: Entries on line 10.0 must be rounded off to the nearest dollar. Ppjiot report cents. Example: Do not report $1,257.75, but
report $1 258 as the amount.
OSHA No. 102FF
SUMMARY REPORT OF FEDERAL OCCUPATIONAL PROPERTY DAMAGE INCIDENTS
8.0 Total Incidents
9.0 Vehicle Usage:
9.1 -Total Miles Traveled
9.2-Total Hours Operated
10.0 Cost of Repair and/or
, Replacement- -Direct
Dollars
1.0 Automobiles
1.1
Gov't
1.2
Private
2.0
Cranes,
Lifts,
Etc.,
3.0
Marine
4.0
Aircraft
5.0
Other Than
Vehicles
. L
6.0
Fire
7.0
Tort
Claims
(Dollars)
•
Figure 3-3. OSHA Forms 102F and 102FF
(Part 4 of 4)
TN 3
1-8-76
-------
INTRODUCTION
Each accident is to be investigated and reported by the immediate supervisor of the
employee involved. In cases involving the public and in cases of property damage
where no employee can be clearly identified as being involved, the Administrative
Officer shall be responsible for completing the Supervisor's Report of Accident.
The term "accident" is not limited to personal injuries. "Accident" also includes
any unplanned incident which results in a vehicle collision, fire, damage to equip-
ment, supplies or other property. We are concerned with the collection of usable
'data about the causes of accidents. We are not interested in finding fault with
individuals. Data from accident reports will be used as the basis for corrective
action.
This booklet is your guide for completing both sides of the Safety Officer's
Analysis of Accident (EPA Form 1440-7). Each item in the report has a definite
purpose; none should be left blank unless you are directed to do so. Each item
is listed in numerical order, with an explanation of its purpose and how the
information should be given.
The errors which result in accidents are often related to factors over which the
employee or supervisor has little direct control. The .facilities, equipment,
working environment, job procedures and staff services may be deficient, but
those deficiencies may not be recognized unless you communicate them on the
accident report. Th§ time which you invest in thoughtful reporting will help
to improve working conditions throughout the Agency.
When more than one employee and/or piece of property is involved in the same
accident, a separate report shall be made for each. Include only that data
needed for the added loss in the additional report(s) since the primary report
will contain all the basic cause/cost data. In cases of personal injury, the
additional reports should be completed in Items 6, 7, 8, 9, 10, 11, 12, 13, 14, 15,
19, 20, 21, 22, 23, and 24. In cases of property damage, the additional reports
should be completed in Items 16, 17, 18, 35, and 36. Staple multiple injury/property
damage reports to basic report so they will not be separated. DO NOT STAPLE
unrelated accident reports together.
Always identify the driver most directly associated with the vehicle in unattended
motor vehicle accident cases. Remember, we are collecting causal data, not placing
blame.
Pads containing sets of EPA Form 1440-7 Forms may be ordered through Agency channels.
It is a stock item. The report is completed in triplicate or, in the case of
regional employees, in quadruplicate. Please type all information.
Retain copy Number 1 and route the additional copies to the Agency Safety and Health
Officer and Officer-in-Charge of the Reporting Unit. If regional employees are
involved, a copy must be retained by the Regional Safety Officer.
CHAP 3 Appendix 3-A TN 3
i 1-8-76
-------
TABLE OF CONTENTS
Introduction
Section A - Identity Data Page
1 Organizational Code 1
2 Reporting Station 1
3 State in Which Accident Occurred 1
4 Date of Accident 2
5 Nearest hour of Accident 2
6 Employee's Name 2
7 Employee's Social Security Number 2
8 Employment Status 3
9 C.S.C. Occupational Code 3
10 Usual Assignment 4
11 Actual Assignment 4
12 Number of Months at This Type Work 5
13 Age of Employee 5
14 Sex of Employee 5
15 Grade 5
16 Identification of Property or Equipment 6
17 Property or Equipment Ownership 6
18 Age of Property or Equipment 6
Section B - Medical
19 Nature of Injury or Illness 7
20 Part of Body Injured 8
21 Severity of Injury 9
22 C.A. Forms 9
23 Type of Accident 9
24 Lost Time and Other Data 10
Section C - Narrative Description
25 Who? What? When? Where? How? 10
Section D - Facility and/or Regional Safety Officer's Opinion
26 Policy or Procedure Improvement 10
Section E - Agency of Accident
27 Direct Agent 10
28 Contributing Agent 21
29 Defect of Agent 22
TN 3 Appendix 3-A CHAP 3
l-S-76
-------
Section F - Working Environment Page
30 Natural Environmental Factor 23
31 Policy and Planning 24
32 Operational Procedures 24
Section G - Staff Services
33 Personnel Related Factors 26
34 Facilities Related Factor 29
Section H - Cost Data
35 Estimated Damage, Government Property 31
36 Estimated Damage, Non-Government Property 31
Section I - Corrective Action
37 Local Corrective Action 31
38 Agency (or Regional) Assistance Requested 31
39 Name of Reporting Supervisor (Who Submitted
Original SF 92) 31
40 Signature-of Facility and/or Regional Safety Officer 31
41 Date 32
42 Other Corrective Action Taken or Planned 32
43 Request for Agency Assistance 32
44 Accident Recordable 32
45 Initials of Regional Safety Officer (If Applicable). 32
46 Signature of Reviewer - Occupational Safety and
Health Staff ...... 32
Definitions of Terms for Use in Recording Federal
Occupational Injuries and Illnesses Exhibit "A"
CHAP 3 Appendix 3-A 0-
iii 1-8-76
-------
4. Date of Accident
May 14 71
Month Day Year
0
5
1
4
7
1
This six digit code identifies the exact date on which the accident occurred. Note that
zeros are used to create a six digit code in all cases. The first two boxes identify the
month from 01 (January) to 12 (December). The next two identify the day, and the last
two identify the year.
Note: Occupational diseases such as silicosis, heart trouble, etc., may be compensable by
law, but one cannot always know the exact date that the disease started. In such cases,
code the date the diagnosis was made or that the accident report was made out. DO NOT
WRITE IN "UNKNOWN"!
5. Nearest Hour of Accid
ent
1
8
This two digit code identifies the time of the accident to the nearest hour, using a
twenty-four hour clock. This accident occurred at about 6 o'clock in the evening. If the
time is unknown use code "99".
6. Name
S
M
I
Last
T
H
7. Social Security Number
First M.I.
James E.
5
2
7
3
49439
Where more than 10 spaces are required for the last name, give only the first ten letters
and omit the remainder. Use a separate form for each employee involved, as explained in
the introduction. Note: If there is no person who is related in any way to the accident,
write in "Unknown". Leave blank items 7,8,9, 10, 11, 12, 13,14, 15, 19, 20, 21, 22 and
24.
CHAP 3
Appendix
2
3-A
TN 3
1-8-76
-------
8. Employment Status
1. Permanent
2. Temporary
3. Contractor
4. Public
5.Other
This code identifies the status of employment under which the employee was hired. If in
doubt, consult your Personnel Officer.
For example: The employee involved in this incident was of permanent status.
Complete a report for a person not employe^ by the Agency at any time that the causal
conditions are pertinent to Agency activities.
9. CSC Occupational Code
1
Last
No.
Here
t
0
0
8
1
9
Insert the Civil Service Commission occupational series of the employee involved in the
accident. Fill in the boxes so that any remaining unneeded boxes are on the left. The
unneeded boxes should have "0" in them, as in the example above. If the employee is
Commissioned Corps, select the most equivalent Civil Service Series.
For example: This employee is a Sanitary Engineer in Civil Service Series GS-819. In case
of doubt, consult the Personnel Officer.
Note: Do not insert the employee's grade into this item.
TN 3
1-8-76
Appendix 3-A
3
CHAP 3
-------
10. Usual Assignment
Last digit here
Parking
Lot
11. Actual Assignment
Last digit here
Laboratory,
Chemical
0
The work assignment identifies where the employee was working at the time of the
accident. It may or may not be where he is ordinarily assigned. For both items No. 10
and No. 11, select from the codes listed below. In this example, the employee is usually
assigned to a parking lot, but was working in the chemical laboratory at the lime of the
accident.
01. Office
02. Laboratory, chemical
03. Laboratory, biological
04. Laboratory, radiological
10. Small shop
11. Power plant
12. Equipment room (pumps,
compressors, etc.)
13. Warehouse, supply area, etc.
14. Maintenance of building
20. Custodial, janitorial, etc.
21. Parking lot (inside)
22. Kitchen-type facilities
23. Mobile structures
30. Physical security
(guards, etc.)
40. Printing and Reproduction
49. Other (specify)
50. Open land (not otherwise
included below)
51. Forest, wooded areas
52. Rough terrain (not adjacent
to water)
53. Streets, roads, highways, etc.
54. Parking lots and areas
60. In, on, or about oceans
(not in watercraft)
61. In, on, or about lakes
(not in watercraft)
62. In, on, or about river/streams
(not in watercraft)
70. Watercraft-over 65'
71. Watercraft-40' to less than 65'
72. Watercraft-26' to less than 40'
73. Watercraft-16' to less than 26'
74. Powered watercraft - less than 16'
75. Rowboats, canoes, etc.
80. Construction sites
81. Mines
82. Tower, elevated structures
90. Submersibles
91. Fixed wing aircraft
92. Helicopters
93. Motor vehicles
94. Heavy duty equipment
98. Other (specify on Accident Report Form)
99. Unknown
CHAP 3
Appendix 3-A
TN 3
1-8-76
-------
12. No. of Months at This Type of
Work
0
0
0
The number of months stated must be for the actual work assignment at time of accident.
If less than one half month, record zeros (O's). All other time periods are recorded to the
nearest whole month. In the example above, the employee was inexperienced in the
actual assignment.
13.
Age
of
Empl
oyee
3
9
The age of an employee can be important when analyzing many accidents within an
occupational group. Age could be important when dealing with fatigue and arduous work
problems.
14. Sex of Emplc
>yee
1
Code 1 for male employee; Code 2 for female employee
15. Grade
W
G
0
5
Code the first two boxes in accordance with the following:
General Schedule Employee
Wage Grade Employee
Wage Leader
Wage Supervisor
Wage Printer
Commissioned Corps
All Others
GS
WG
WL
WS
WP
CC
9999
Code the last two boxes with a numerical grade. In the example above the employee is a
Wage Grade 05. Use a zero if needed, as above.
TN 3
1-8-76
Appendix 3-A
5
CHAP 3
-------
16.
Identification
Name:
Model:
Size:
Floor
of Property or Equipment Damaged (if any)
Make:
Type:
5
8
0
1
This code identifies the property or equipment damaged, if any. If no property or
equipment damage occurred, record zeros (O's) in all blocks. When more than one
category of property was damaged, identify that property where the major damage
occurred. Submit a separate report for each piece of property or equipment when the
damage is $50.00 or more to each. The coding guide index (on page 11) is the same as
used for Item 27 on the Supervisor's Report of Accident. Write in specific information
such as device name, model, make, etc., if available. This type of specific information
may be helpful in identifying defects or difficulties with certain makes or models of
equipment.
17. Property or Equipment Ownership
0. No Property
1. EPA Owned
2. GSA Motor Pool
3. Other Federal
4. Contractor Owned
5. Employee Owned, on
Official Business
6. Privately Owned
7. Other (explain)
Any Agency property or equipment damaged in the accident should be identified in the
report as Code 1. If the property or equipment (other than a motor vehicle) is under the
custody of some other Agency, code it 3. If the property is a motor vehicle from a GSA
Motor Pool, code it 2. In the example above, the property was EPA owned.
18.
Age of Prop
or Equipme
•erty
nt
0
5
Age of vehicles or other property or equipment which is damaged alerts management
when property should be discarded as too old or obsolete. Property or equipment that is
18 months old or less should be coded as "01". Other property or equipment should be
coded to the nearest whole year. If there is no property or equipment involved, code
"00".
CHAP 3
Appendix 3-A
6
TN 3
1-8-7*
-------
19. Nature of Injury
or Illness
NATURE OF INJURY OR ILLNESS
Definition: Identifies the personal injury or illness in its principal physical characteristics.
If there are multiple injuries or illnesses, select that which is the most severe. For
example, enter an injury involving a permanent impairment rather than a temporary
disability.
1
Code
00
01
02
03
04
20
21
22
23
24
25
26
40
41
42
43
44
45
46
47
48
Nature of Illness or Disorders
Skin
No Injury or Illness involved
Nature of Injury
Abrasion, bruise, etc.
Burn or heat injury
Irritation
Cut, laceration, puncture, etc.
Bones and Muscles
Fracture
Crushing
Amputation
Dislocation
Strain and Sprain
Hernia
Torn ligament, cartilage
Body Functions and Senses
Sight impairment and
blinding
Hearing impairment and
deafening
Drowning
Air embolism, diving oils
Concussion
Heart attack
Psychological stress
Internal injury, NEC*
Nature of injury unknown
Code
50 Skin diseases or disorders
51 Dust diseases of the lungs
(Pneumoconiosis)
52 Respiratory conditions due
to toxic agents
53 Poisoning (systemic effects
of toxic materials)
54 Disorders due to physical
agents (Other than toxic
materials)
55 Disorders due to repeated
trauma
98 Other (specify)
99 Unknown
1. For definitions of terms for use in recording Federal Occupational Illnesses, please see Appendix to these instructions
* Nof Elsewhere Classified
TN 3
1-8-76
Appendix 3-A
CHAP 3
-------
20. Part
Left
of Body Injure
hand
d
2
5
The identification of part of body injured tells management where protective clothing
and equipment may be needed.
DO NOT TRY TO INSERT MORE THAN ONE CODE. SELECT THE ONE CODE \OU
THINK GIVES THE BEST DESCRIPTION.
Code Body Part
40* Lower Extremities
41 Thigh
42 Leg(s)
43 Knee(s)
44 Foot, not toes
45 Toe(s)
46 Ankle(s)
50* Body Systems
51 Circulatory (heart, blood)
52 Digestive
53 Nervous
54 Respiratory (lungs)
55 Excretory
56 Reproductive
98 Other (specify)
99* Unknown
Code
00
10*
11
12
13
14
15
16
17
18
20*
21
22
23
24
25
26
30*
31
32
33
34
35
36
37
Body Part
No part of body injured
Head Area
Ear(s)
Eye(s)
Face
Skull and scalp
Nose
Jaw
Teeth
Neck
Arm-Hand Area
Upper arm (above elbow)
Lower arm (below elbow)
Elbow(s)
Wrist(s)
Hand(s), not fingers
Fingers
Trunk Area
Abdomen
Back (spine)
Hips
Shoulders
Ribs, chest
Groin
Buttocks
"Use only if not listed elsewhere
CHAP 3
Appendix 3-A
TN 3
1-8-76
-------
21. Severity of Injury
0. No injury involved
1. First aid attention only
2. Medical attention (non-disabling)
3. Disabling injury (temporary)
4. Disabling injury (permanent)
5. Fatality
22. C.A. Forms Pre
Code
Yes 1
jared and Properly Routed?
Code
No 0
C.A. Forms are essential to protect the injured employee's rights and benefits under the
Federal Employees' Compensation Act. The several C.A. Forms are not Agency Accident
Reports. C.A. Forms are forwarded through channels to the Personnel Management
Division.
23. Type of Accident
B
Information in this item enables the grouping of occurrences into standard, broad
categories used by many agencies.
Code TYPE OF ACCIDENT
0 Other (Specify)
1 Struck Against
'2 Struck By
3 Caught In or Between
4 Fall (Same level)
5 Fall (Different level)
6 Slip or Twist (Not a fall)
7 Exposure of External Human Body
8 Exposure of Internal Human Body
9 Contact with Electrical Current
A Unknown
B Property or equipment damage (no personal injury involved)
TN 3
1-8-76
Appendix 3-A
9
CHAP 3
-------
24. Lost Time & Other Data
A. Stopped Work
B. Returned to Work
C. Death Date
Month
Day
Year
No. of Lost Workdays &
Other Data
i
Last
No.
Here
*
0
0
0
0
Number of Whole Days Lost1
Enter in the last three blocks, using zeros where appropriate, the number of whole days
the employee would have worked had he not been injured or ill. Do not include holidays,
weekends, or days in leave status which were not occasioned by the accident. Do not
include the day of accident.
In all cases of Lost Workdays, code the first block as follows:
Code 1 — Employee was permanently transferred Code 2 — Employee was terminated
Code 0 — If neither action is involved
In all Nonfatal Cases Without Lost Workdays, Code the first block as follows:
Code 3 - Medical Treatment beyond first
aid
Code 4 - Diagnosis of occupational illness
Code 5 - Loss of Consciousness
Code 6 - Restriction of work or motion
Code 7 - Transfer to another job without
lost working days
Code 9 - If none of the above actions are
involved
The last three blocks will be coded with zeros for all nonfatal cases without lost
workdays.
25. NARRATIVE
Indicate the place of the accident or exposure to occupational illness and whether it
occurred on Agency's premises. Include name and address of physician. If
hospitalized, give name and address of hospital.
Tell the story as it is, but be brief. Reduce lengthy details and avoid personal blame.
26. IN TERMS OF POLICY OR PROCEDURE IMPROVEMENT, I RECOMMEND THE
FOLLOWING: This item is not coded. It gives the Facility and/or Regional
Safety Officer a chance to tell what night have been done to prevent
the accident.
27. Direct Agent
0
9
0
1
Identifies the Direct Agent of Accident by naming the article, substance, or object which
most proximately caused the accident. When there is a choice of agents, select the one
most closely related to the hazardous condition which can be reasonably corrected. The
Rapid Reference Topical Index, which follows, provides a quick guide to the appropriate
category.
1. For specific definitions to Lost Workdays and Recordable Occupational Injuries and Illnesses please see Appendix to
these instructions.
CHAP 3
Appendix
3-A
10
-------
RAPID REFERENCE TOPICAL INDEX
Source titles are in alphabetical order. The code numbers are not in numerical order. IF
THE SOURCE BEING LOOKED FOR DOES NOT FIT INTO ANY OF THE TITLES
LISTED, NOTE ON THE SAFETY OFFICERS ANALYSIS OF ACCIDENT. EPA FORM
1440-1, SO THAT THE OMISSION CAN BE RECTIFIED IN A LATER REVISION.
Code General Area of Agent
0000 No agent of accident
0100 Air pressure 13
0200 Animal, insects, birds, reptiles 13
0500 Boilers, pressure vessels 13
0600 Boxes, containers, packages 13
(empty or full)
0700 Buildings and structures 13
0900 Chemicals and chemical compounds 14
1000 Clothing, apparel, shoes, cloth 14
1100 Coal and petroleum products 14
1300 Conveyors (non-passenger type) 15
1400 Drugs and medicines 15
4300 Dust and dust particles (mineral items) 19
1500 Electrical apparatus 15
2600 Elevators (hoisting apparatus) 18
1600 Excavations, trenches, tunnels 15
1700 Explosions 16
1700 Firearms 16
1700 Flame, fire and smoke 16
1800 Food products 16
1900 Furniture, fixtures, furnishings 16
2000 Glass and ceramics 16
2200 Hand tools (not powered, portable) 16
2300 Hand tools (powered, portable) 17
2500 Heating equipment (not electric) 17
2600 Hoisting apparatus 18
2700 Infectious and parasitic agents 18
1500 Laboratory equipment (not glassware) 15
2800 Ladders 18
3000 Machines (all kinds, stationary) 18
4000 Mechanical power transmission - 19
(belts, chains, etc.)
4100 Metal items (rods, nails, screws, scrap, etc.) 19
4300 Mineral items (stone, dirt, dust) 19
4400 Noise 19
4500 Paper and paper products 19
TN 3 Appendix 3-A CHAP 3
1-8-76
11
-------
Code General Area of Agent (continued)
4700 Plants, trees, vegetation 19
4800 Plastic and rubber items 19
4900 Pumps and prime movers 20
5000 Radiating substances and equipment 20
1500 Radio and television 15
5800 Surfaces (in use as supports for people) 21
5600 Vehicles 20
5700 Wood or wood products 20
9998 Miscellaneous NEC* 21
9999 Unknown, unidentified 21
*Not Elsewhere Classified
CHAP 3 Appendix 3-A Tw 3
1-8-76
12
-------
Code AGENT
0100* AIR PRESSURE
0200* ANIMALS, INSECTS, BIRDS, REPTILES
0210* Animals, Laboratory
0211 Dogs
0212 Cats
0213 Rats
0214 Mice
0215 Rabbits
0216 Monkeys
0217 Guinea pigs
0218 Marine
0220* Animals, Non-Laboratory
0221 Domestic
0222 Wild
0223 Marine
0500* BOILERS, PRESSURE VESSELS
0501 Water heaters
0502 Water heater controls
0503 Boilers, low pressure
0504 Controls on low pressure boilers
0505 Boilers, high pressure
0506 Controls on high pressure boilers
0510* Pressurized Containers (gases or liquids)
0511 Gas and liquid cylinders
0520* Autoclave
0530* Pressure Lines
0599* Pressure Vessels, NEC**
0600* BOXES, CONTAINERS, PACKAGES
0601 Barrels, Kegs, Drums
0630 Boxes, Crates, Cartons
0650 Bottles, Jugs
0651 Metal cans, safety
0652 Metal cans, non-safety
0653 Glass containers, laboratory (reagent)
0654 Glass containers, other
0670 Tanks, Bins, (not pressurized)
0699 Containers, NEC
0700* BUILDING AND STRUCTURES (not floors, working
surfaces, or walkways)
*Use only if not listed elsewhere
**Not Elsewhere Classified
TN 3 Appendix 3-A CHAP 3
1-8-76
13
-------
Code AGENT
0701 Buildings (office, plant, residential, etc.)
0710 Bridges
0720 Dams, Locks, etc.
0740 Scaffolds, Staging, etc.
0750 Wharfs, Docks, etc.
0799 Buildings and Structures, NEC
0900* CHEMICALS, CHEMICAL COMPOUNDS
0901 Acids
0905 Alcohols
0910 Alkalies
0915 Aromatic Compounds (Benzol, Toluene,
Xylene, Aniline, etc.)
0920 Arsenic Compounds
0930 Carbon Dioxide
0935 Carbon Monoxide
0940 Carbon Tetrachloride
0945 Cyanides or Cyanogen Compounds
0950 Halogenated Compounds (Tricholorethylene,
Perchlorethylene, Methyl Chloride, Refrigerants)
0955 Metallic Compounds (Lead, Mercury, Zinc, etc.)
0960 Oxides of Nitrogen
0970 Agricultural
0971 Pesticides
0972 Herbicides
0973 Fertilizers
0999 Chemicals and Chemical Compounds, NEC
1000* CLOTHING, APPAREL, SHOES, CLOTH
1001 Boots, Shoes, etc.
1010 Gloves
1020 Hats, Head Coverings
1030 Outer Coats, Rainwear
1040 Shirts, Sweaters, Inner Coats
1050 Suits, Pants, Coveralls, Dresses
1060 Stockings, Leggings, Socks
1070 Underwear
1099 Apparel, NEC
1100* COAL AND PETROLEUM PRODUCTS
1101 Coal, Code
1120 Crude Oil, Fuel Oil
1130 Gasoline and Liquid Hydrocarbon Compounds
1140 Hydrocarbon Gases (Methane, Ethane, Ethylene,
Propane, Butane, Isobutane, Butylene, Isobutylene,
LP Gas, etc.)
1150 Kerosene
CHAP 3 Appendix 3-A TN 3
1-8-76
14
-------
Code AGENT
1160 Lubricating and Cutting Oils and Greases
1170 Manufactured Gases
1180 Naphtha Solvents (Petroleum Ether, Mineral Spirits,
Rubber Solvents, Stoddard Solvent, Aromatic
Solvents, etc.)
1190 Petroleum Asphalts, Road Oil
1199 Coal and Petroleum Products, NEC
1300* CONVEYORS
1301 Gravity Conveyors
1350 Powered Conveyors
1400* DRUGS AND MEDICINES
1401 Biologic Products
1490 Other Medicinals
1500* ELECTRICAL APPARATUS
1501 Motors, Generators
1510 Transformers, Converters
1515 Conductors, Wires
1520 Switchboard and Bus Structures, Switches,
Circuit Breakers, Fuses
1530 Rheostats, Starters, Control Apparatus, Capacitors,
Rectifiers, Storage Batteries
1540 Magnetic and Electrolytic Apparatus
1541 Radio and television
1542 Movie projectors
1543 Projectors, other
1550 Heating Appliances
1551 Hot plates, laboratory
1552 Ovens, laboratory
1553 Heating strips, tapes, laboratory
1554 Water, office use
1555 Food preparation
1556 Space heaters
1560 Laboratory, Analytical
1561 Atomic absorption
1562 Gas chromatograph
1563 Gas Analyzer
1564 Microscope, light
1565 Microscope, electron
1566 Recorder
1567 Laser
1570 Air Conditioning Equipment
1580 Welding
1599 Electrical Apparatus, NEC
1600* EXCAVATIONS, TRENCHES, TUNNELS
1610 Excavations for buildings, roads, etc.)
TN 3
Appendix 3-A CHAP 3
15
-------
Code AGENT
1620 Mine Shafts, Entries
1630 Trenches
1640 Tunnels
1699 Excavations, NEC
1700* EXPLOSIONS, FIRE, FLAME, SMOKE, FIREARMS
1701 Explosions
1702 Ruptured containers, small
1703 Ruptured containers, large
1704 Explosives, commercial
1705 Explosives, chemicals (other than commercial)
1706 Gaseous mixtures
1707 Particle mixtures
1710 Fire
1711 Solid material
1712 Gaseous mixture
1713 Liquids
1720 Implosion
1730 Firearms
1740 Smoke
1800* FOOD PRODUCTS, INCLUDING ANIMAL FOODS
1900* FURNITURE, FIXTURES, FURNISHINGS
1901 Cabinets, File Cases, Bookcases, etc.
1910 Chairs, Benches, etc.
1920 Counters, Work Benches, etc.
1930 Desks, Tables
1950 Floor Coverings, Carpets, Rugs, Mats, etc.
1960 Lighting Equipment
1999 Furniture, Fixtures, NEC
2000* GLASS, CERAMIC ITEMS, NEC
2001 Laboratory
2002 Flasks, beakers
2003 Tubing
2004 Piping
2010 Flat or Curved Glass
2011 Windows (viewing)
2012 Other, NEC
2020 Light Bulbs, Fluorescent Tubes, Flash Bulbs
2030 Dishware
2200* HAND TOOLS, NOT POWERED
2201 Cutting, Sawing and Scraping Type
2202 Axe, hatchet
2203 Chisel
2204 File, Rasps
2205 Knife
CHAP 3 Appendix 3-A TN 3
1-8-76
16
-------
Code AGENT
2206 Plane
2207 Saw
2208 Scissors, paper cutter
2209 Scythe, sickle
2210 Striking, Punching Type
2211 Hammer, sledge, mallet
2212 Pick
2213 Punch, awl
2220 Prying, Lifting and Turning Type
2221 Crowbar, prybar
2222 Pliers, tongs
2223 Screwdriver
2224 Wrench
2230 Miscellaneous Types
2231 Fork, rake
2232 Shovel, spade
2233 Rope, chain
2234 Brooms, brushes, mops
2235 Can openers
2300* HAND TOOLS, POWERED
2301 Cutting, Sawing and Scraping Type
2302 Abrasive stone and wheel grinder
2303 Chisel
2304 Drill
2305 Knife
2306 Circular saw
2306 Chain saw
2307 Planer
2310 Striking, Punching Type
2311 Punch
2312 Hammer, tamper
2313 Riveter
2320 Prying, Lifting and Turning Type
2321 Screwdriver
2322 Wrench
2330 Miscellaneous Types
2331 Buffer, polisher, waxer
2332 Lawn mower
2333 Hedge trimmers
2400* HEAT, ATMOSPHERIC, ENVIRONMENTAL (not hot
objects or substance)
2500* HEATING EQUIPMENT (non-electrical)
2501 Space Heating
2502 Furnace, oil fired
2503 Furnace, gas fired
XN 3 Appendix 3-A CHAP 3
1-8-76
17
-------
Code AGENT
2510 Heating, Food Preparation
2520 Heating, Miscellaneous
2521 Blow torch
2522 Cutting or welding torch
2523 Melting, fusing
2524 Incineration
2526 Boiling, distillation, reacting
2600* HOISTING APPARATUS
2601 Cranes, Derricks
2610 Elevators
2620 Other Hoisting Apparatus
2621 Air hoist
2622 Chain hoist, chain blocks
2623 Electric hoist
2624 Jacks
2625 Hydraulic tailgage
2700* INFECTIOUS AND PARASITIC AGENTS
2710 Tuberculosis
2720 Pneumoconiosis (inorganic dusts)
2730 Dermatitis
2740 Toxic Metals
2750 Infectious and Parasitic Agents (bacteria
fungi, virus)
2760 Heart Disease
2799 Diseases, Occupational, NEC (specify)
2800* LADDERS (fixed and portable)
2810 Fixed Ladders
2830 Movable
2831 Extension ladders
2833 Step ladders
2835 Straight, single ladders
2899 Ladders, NEC
3000* MACHINES
3001* Machine Shop Type
3002 Lathe
3003 Drill press
3004 Milling machine
3005 Grinder, sander, polisher
3006 Metal forming machine
3010 Woodwork Shop Type
3011 Table saw
3012 Jointer
3013 Shaper
3014 Planer
3015 Sander
CHAP 3 Appendix 3-A TN 3
18
-------
Code AGENT
3020 Office Machinery
3021 Typewriter
3022 Duplicating
3023 Calculator
3024 Dictating
3030 Laboratory Machines
3031 Shaker
3032 Grinders and crushers
3033 Mixers
4000* MECHANICAL POWER TRANSMISSION APPARATUS
4010 Belts
4020 Chains, Ropes, Cables
4030 Drums, Pulleys, Sheaves
4040 Friction Clutches
4050 Gears
4099 Mechanical Power Transmission Apparatus, NEC
4100* METAL ITEMS, NEC (does not include ores or raw
minerals)
4101 Plates
4110 Wire
4120 Nails (nails in boards)
4130 Nuts, Bolts
4140 Pipe
4150 Molten Metal
4160 Scrap Iron
4199 Metal Items, NEC
4300* MINERAL ITEMS
4301 Sand, Gravel, Stone
4310 Dirt, Dust
4399 Mineral Items, NEC
4400* NOISE
4500* PAPER AND PULP ITEMS, NEC
4501 Stationery
4510 Bags
4520 Cardboard
4599 Paper and Pulp Items, NEC
4700* PLANTS, TREES, VEGETATION
4701 Poison Ivy, Sumac, Oak, etc.
4710 Thorns, Briars
4720 Branches, Twigs
4725 Tree Trunk, Large Limbs
4730 Nettles
4799 Plants, Trees, Vegetation, NEC
4800* PLASTIC AND RUBBER ITEMS, NEC
TN 3 Appendix 3-A CHAP 3
1-8-76
19
-------
Code AGENT
4900* PUMPS AND PRIME MOVERS
4910 Engines (steam and internal combustion)
4930 Pumps
4950 Turbines (hydraulic, air, etc.)
5000* RADIATING SUBSTANCES AND EQUIPMENT (Use this
code only in cases of radiation injuries)
5010 Isotopes and Irradiated Substances
5020 Radium
5030 Reactor Fuel, Raw or Processed
5040 Reactor Wastes
5050 Sun
5060 Ultraviolet Equipment
5070 Welding Equipment, Electric Arc
5080 X-ray and Fluoroscope Equipment
5090 Laser and Maser Equipment
5099 Radiating Substances or Equipment, NEC
5100* SOAPS, DETERGENTS, CLEANING COMPOUNDS, NEC
5200* SILICIA
5300* SCRAP, DEBRIS, WASTE MATERIALS, NEC
5400* STEAM
5600* VEHICLES
5601 Animal Drawn
5610 Aircraft
5620 Highway Vehicles, Powered.
5621 Passenger type buses
5622 Sedan, coupe
5623 Station wagon
5624 Pick up truck
5625 Panel truck (Carryall)
5626 Truck under 2 tons
5627 Truck over 2 tons
5630 Plant or Industrial Vehicles
5631 Hand trucks, dollies, and other non-powered
vehicles
5635 Forklift, stackers, lumber carriers, etc.
5638 Mules, tractors, and other powered towing
vehicles
5640 iRail Vehicles
5650 Sleds, Snow and Ice Vehicles
5660 Water Vehicles
5670 Construction Type Vehicles
5699 Vehicles, NEC.
5700* WOOD ITEMS
5701 Plywood Products
5710 Lumber
CHAP 3 Append!: 3-A TN 3
1-8-76
20
-------
Code AGENT
5720 Poles, Logs
5730 Chips, Splinters
5799 Wood or Wood Product, NEC
5800* WORKING SURFACES (in use as supports for people)
5801 Floor (of a building, scaffold, staging, vehicle, etc.)
5810 Ground (outdoors)
5815 Ramps
5820 Roofs
5825 Runways or Platforms (permanent elevated surfaces)
5830 Sidewalks, Paths, Walkways
5840 Stairs, Steps
5845 Street, Road
5899 Working Surfaces, NEC
9998*
9999*
MISCELLANEOUS, NEC
AGENCY OF ACCIDENT UNKNOWN
28. Contributing Agent
Shelf
1
9
9
9
The same coding index is used for this item as Item 27. The contributing agent is that
item which acted upon or with the immediate agent to cause the accident. To illustrate
the relationship between Item 16, Identification of Property or Equipment Damaged,
Item 27, Direct Agent, and Item 28, Contributing Agent, consider this simplified
example: A shelf collapses, breaking a jar of acid which damages the floor. The acid is the
direct agent, while the shelf is the contributing agent. Note that the contributing agent
may be more important than the direct agent in terms of causal conditions. In case there
is no contributing agent in Item 28, all blocks should be filled in with zeros (O's). When
there is a choice of contributing agents, select the one that is most directly related and
which can be reasonably corrected. In the example above, a shelf (fixture) was the
Contributing Agent.
TN 3
1-8-76
Appendix 3-A
CHAP 3
-------
29. Defect of Agent
0
0
Bent
2
2
Report any defect of agent, direct and contributing. If no defect is observed, indicate by
filling O's in blocks. Enter defect of direct agent in boxes on left of Item 29 (boxes 92-93)
and defect of contributing agent in boxes on right of Item 29, (boxes 94-95).
Code DEFECT OF AGENT
00* No Defect
10* Defective Construction
11 Design (Configuration, size, dimensions, etc.)
12 Construction (Method of making)
13 Material (Selection of material)
20* Defective Physical Condition (Man-made or conditioned)
21 Worn
22 Cracked or Broken
23 Frayed, Torn, or Cut
24 Slippery or Slick
25 Rough or Barbed
26 Twisted or Tangled
27 Deformed or Bent
28 Dull
29 Sharp
30* Defective Physical Condition (Natural environment conditioned)
31 Eroded
32 Corroded
33 Etched
34 Rusted
35 Excessive Heat
36 Excessive Cold
37 Wet
40* Defective Vehicle
41 Braking System
42 Lighting and Signal System
43 Wheel, Axle, Propeller Spindle, Bearings, Drive Train
(Exclude engine), etc.
44 Tire
45 Engine
46 Instruments and Gauges
47 Steering and Other Controls
48 Glass (Viewing)
49 Doors, Windows, Fenders, Bumpers
98* Other
99* Unknown
*Use only if specific items are not suitable or if exact circumstances are unknown.
CHAP 3 TN .3
Appendix 3-A 1-8-76
22
-------
30. Natural Environmental Factor
0
0
Natural environmental factors (weather and climatic conditions) which relate to the
accident must be reported. More than one condition can exist at one moment. Select only
the major factor applicable.
Code FACTOR
00 No Factor Relates
10* Wind
11 0-10 mph (miles per hour)
12 10-30 mph
13 30-60 mph
14 Greater than 60 mph (if not covered by Item 50)
Rain
21 Heavy Rain
22 Freezing Rain
23 Sleet, Hail
Snow or Ice
Fog
Major Weather, Earth or Water Movements
51 Tornado, Hurricane or Cyclone
52 Tidal Wave
53 Flood (River, Creek, Wash, etc.)
54 Earthquake
55 Slides (Rocks, Mud, etc.)
56 Avalanche (Snow)
57 Lightning
*Use only if specific items are not suitable or if exact circumstances are unknown.
20*
30*
40*
50*
TN 3 '
1-8-76
Appendix 3-A
CHAP 3
23
-------
33. Personnel Related Factor
0
0
0
All categories are primarily personnel activities.
Select appropriate code for most significant conditions leading to or directly involved
with relation to accident. If more than one factor was significant, select the one single
factor that contributed the most to create the accident.
Code FACTOR
000* None of the Following
100* Inadequate or No Training**
**If a specific training category can be related to the accident problem in any
way, it would help support training needs by selecting of the following:
110 Services of Professional Safety Officer Needed
111 Orientation to-the-job
112 Training for Supervisors
113 Technical, Scientific, Professional Training
114 Skill Training for Office, Clerical People
115 Skill Training for Particular Trade or Craft Involved
116 Defensive Driving
117 Other (Specify)
120 Emergency Task, No Time to Train
130 Work Pressure Allows No Time for Adequate Training
140 Trained Employee Did Not Follow What He Had Been Taught
CHAP 3 Appendix 3-A TN 3
26 l~*-7*
-------
200* Communications Factors
210 Non-Existent
220 Lack of dear Instructions - Verbal
230 Lack of Clear Instructions --Written
240 Ineffective Between Management Levels
250 Ineffective Between Management and Outside Organizations
300* Improper Skills
310 Limited Skill
320 Undeveloped Skill «
330 Misapplication of Skill
400* Supervisory Factors
410 Area of Responsibility Not Clear
420 Too Many People to Adequately Supervise
430 Union Dispute Regarding Supervision
440 Person Supervised in Other Location (Building, location, travel status, etc)
450 Work Violation, Written or Verbal Instruction
ra 3 Appendix 3-A CHAP 3
1-8-76 27
-------
Code FACTOR (continued)
460 Insubordination, Misconduct
500* Fitness for Duty
510 Work Fatique (Regular working hours)
520 Work Fatigue (Overtime)
530 Emotional Upset
540 Allergy
550 Suspected Intoxication, Drugged
560 Amputation
570 Vision
580 Hearing
590 Respiratory
599 Other Chronic or Impaired Condition or Illness
600* Improper Placement or Staffing
610 Task Unrelated to Capabilities
620 Need a Better Trained Person, But Unavailable
630 Inadequate Number of Persons to Perform Task
640 Too Many Persons for Task
650 Performing Task Unrelated to Position
700* No License
710 Motor Vehicle
720 Craft
730 Operator (Equipment)
740 AEG (Radioactive sources)
750 Professional (Other)
CHAP 3 „ , Tv, o
Appendix 3-A TN 3
28 1-8-76
-------
Code
800*
999°
FACTOR (continued)
Other Factors
810 Health Services Insufficient
820 Dual Employment
830 Work Unauthorized
Unknown
*Use only if not listed elsewhere
34. Facilities Related Factor
Unsafe Chemical Storage Area
6
3
0
Select the one coded response that identifies the most serious facility deficiency which
contributed to the accident.
Code FACTOR
000* None
100* Hazardous Working Areas (Floor)
110 Uneven or Unlevel
120 Unstable
130 Too Small
140 Unclean, Cluttered
150 Rough (Pitted, holes, cracks)
160 Slippery
170 Layout Unsatisfactory
200* Hazardous Working Area (Room)
210 Ineffective Ventilation
220 Extreme Temperatures
230 Inadequate Lighting
240 Insufficient Noise Control
250 Inadequate Fire Alarm System
260 Inadequate Fire Suppression System
270 Inadequate Exit Ways
TN 3
1-8-76
Appendix 3-A
29
CHAP 3
-------
Code FACTOR (continued)
300* Traffic Areas (Hallways, etc.)
310 Too Narrow
321 Insufficient Lighting
330 No Warning or Directional Signs
350 Inadequate Guards, Rails
360 Emergency Exits Inadequate
400* Hazardous Building and Grounds Factor
410 Sanitation Facilities
420 Parking Facilities
430 Fire Partitions
450 Unsafe Structure (Tanks, supports, bridges, etc.)
460 Roads (Size, location, etc.)
470 Fencing, Guard Rails, etc.
480 Traffic Control Signs, Signals, or Lights
500* Unsafe Facility Equipment
510 Boiler or Controls
520 Water Tank or System
530 Fuel Storage and Lines
540 Electric Power Substation or Service Lines
550 Cooling Towers, Lines, or Treatment Facilities
560 Sewage or Industrial Waste Collection System or Plant
570 Exhaust Blowers and Stacks
600* Unsafe Material Handling Areas or Facilities
610 Trash and Garbage Disposal
620 Loading and Unloading Facilities or Areas
630 Chemical Storage Area
631 Flammable Chemical Storage Area
632 Explosive Chemical Storage Area
633 Toxic Chemical Storage Area
640 Gas Cylinder Storage
999* Unknown
*Use only if specific items are not suitable or if exact circumstances are unknown.
CHAP 3 Appendix 3-A TN 3
1-8-76
30
-------
35. Est. Damage, Gov't. Property
(Dollars only -omit cents)
1
Last No.
Here
t
0
0
1
9
0
36; E
(
Las1
Her
st. Damage, non-Gov't. Property
Dollars only -omit cents)
tNo.
e
t
0
0
0
0
0
Identifies the cost of repairs or replacement of property damaged in the accident. ENTER
COSTS IN WHOLE DOLLAR AMOUNTS-OMIT CENTS.
Summarize all the cost to the Government for repairs or replacement of its property that
is damaged by the accident and insert that figure in Item 35. A timely estimate is
preferred over an accurate total that will delay submission of the report.
Summarize all the loss claimed by the "other" party (non-Federal property) as a result of
the accident and insert this figure in Item 36.
The Government dollar loss is being data processed so that summarized loss figures can be
given to management. Reasonable estimates are acceptable. The cost data of repairs or
replacement claimed by the "other" party will provide a reasonable estimate of any claim
that may be expected.
37. LOCAL CORRECTIVE ACTION TAKEN OR PLANNED: Code Yes 1, No 0
Identifies the specific action planned or taken to correct the cause of the accident. If
action is planned, explain briefly. Indicate person responsible for taking action!
38. AGENCY (OR REGIONAL ASSISTANCE REQUESTED?
Self-explanatory
39. NAME AND TITLE OF REPORTING SUPERVISOR.
Furnish title and Civil Service Commission Occupational Code of Reporting
Supervisor who submitted the original SF 92.
40. SIGNATURE OF FACILITY AND/OR REGIONAL SAFETY OFFICER
Self-explanatory
TN 3
1-8-76
Appendix
31
3-A
CHAP 3
-------
41. DATE
Self-explanatory
42.- OTHER CORRECTIVE ACTION TAKEN OR PLANNED:
Identifies the non-local corrective action that the management will
take or has taken in carrying out corrective measures. Indicate
title of person responsible for taking action.
43.. REQUEST FOR AGENCY ASSISTANCE
Identifies the action that the Facility and/or Regional Safety Officer
feels that the Agency should consider to assist in carrying out
Agency-wide corrective measures.
44 . ACCIDENT RECORDABLE
To be completed by the Facility and/or Regional Safety Officer,
Code - Yes 1, No.O.
Definition: Recordable Occupational Injuries and Illnesses are any occupational
injuries or illnesses which result in:
a. Fatalities, regardless of the time between the injury and death, or the length of
the illness; or
b. I ost Workdays Cases, other than fatalities that result in lost workdays; or
c. Nonfatal Cases Without Lost Workdays, which result in transfer to another job or
termination of employment, or require medical treatment (as defined below), or
involve loss of consciousness or restriction of work or motion. This category also
includes any diagnosed occupational illnesses which are reported but are not
classified as fatalities or lost workday cases.
Medical Treatment includes treatment administered by a physician or by
registered professional personnel under the standing orders of a physician. Medical
treatment does not include first aid treatment (one-time treatment and subsequent
observation of minor scratches, cuts, burns, splinters, and so forth, which do not
ordinarily require medical care) even though provided by a physician or registered
professional personnel.
45- INITIALS OF REGIONAL SAFETY OFFICER (l£ applicable)
Self-explanatory
46. SIGNATURE OF REVIEWER - OCCUPATIONAL SAFETY AND HEALTH OFFICER AND DATE.
Self-explanatory
CHAP 3 Appendix 3-A TN 3
1-8-76
32
-------
EXHIBIT "A"
DEFINITIONS OF TERMS FOR USE IN RECORDING
FEDERAL OCCUPATIONAL INJURIES AND ILLNESSES
L. OCCUPATIONAL INJURY is any injury such as a cut, fracture, sprain, amputation,
• etc., which results from a work accident or from exposure in the work environment.
I. OCCUPATIONAL ILLNESS of an employee is any abnormal condition or disorder,
other than one resulting from an occupational injury, caused by exposure to
environmental factors associated'with his employment. It includes acute and chronic
illnesses or diseases which may be caused by inhalation, absorption, ingestion, or direct
contact, and which can be included in the categories listed below.
The following listing gives the categories of occupational illnesses and disorders that
tvill be utilized for the purpose of classifying recordable illnesses. For purposes of
nformation, examples of each category are given. These are typical examples, however,
uid are not to be considered to be the complete listing of the types of illnesses and
Usorders that are to be counted under each category.
a. Occupational Skin Diseases or Disorders
Examples: Contact dermatitis, eczema, or rash caused by primary irritants and
sensitizers or poisonous plants; oil acne; chrome ulcers; chemical burns or
inflammations; etc.
b. Dust Diseases of the Lungs (Pneumoconioses)
Examples: Silicosis, asbestosis, coal worker's pneumoconiosis, byssinosis, and other
pneumoconioses.
c. Respiratory Conditions Due to Toxic Agents
Examples: Pneumonitis, pharyngitis, rhinitis or acute congestion due to chemicals,
dusts, gases, or fumes; farmer's lung; etc.
d. Poisoning (Systemic Effects of Toxic Materials)
Examples: Poisoning by lead, mercury, cadmium, arsenic, or other metals,
poisoning by carbon monoxide, hydrogen sulfide or other gases; poisoning by
insecticide sprays such as parathion, lead arsenate; poisoning by other chemicals
such as formaldehyde, plastics and resins; poisoning by benzol, carbon
tetrachloride, or other organic solvents.
e. Disorders Due to Physical Agents (Other Than Toxic Materials)
Examples: Heatstroke, sunstroke, heat exhaustion and other effects of
environmental heat; freezing, frostbite and effects of exposure to low temperatures;
caisson disease; effects of ionizing radiation (isotopes, X-rays, radium); effects of
non-ionizing radiation (welding flash, ultraviolet rays, microwaves, sunburn), etc.
f. Disorders Due to Repeated Trauma
Example: Noise-induced hearing loss; synovitis, tenosynovitis, and bursitis;
Raynaud's phenomena; and other conditions due to repeated motion, vibration or
pressure.
3 Appendix 3-A CHAP 3
-76 33
-------
g. All Other Occupational Illnesses
Examples: Anthrax, brucellosis, infectious hepatitis, malignant and benign tumor
food poisoning, histoplasmosis, coccidioidomycosis, etc.
I
3. RECORDABLE OCCUPATIONAL INJURIES AND ILLNESSES are any occupation)
injuries or illnesses which result in:
1. FATALITIES, regardless of the time between the injury and death, or the length c
the illness; or
2. LOST WORKDAYS CASES, other than fatalities that result in lost workdays; or
3. NONFATAL CASES WITHOUT LOST WORKDAYS, which result in transfer t
another job or termination of employment, or require medical treatment (i
defined below), or involve loss of consciousness or restriction of work or motioi
This category also includes any diagnosed occupational illnesses which are reporte
to the Agency but are not classified as fatalities or lost workday cases.
MEDICAL TREATMENT includes treatment administered by a physician or b
registered professional personnel under the standing orders of a physician. Medic
treatment does NOT include first aid treatment (one-time treatment and subscquer
observation of minor scratches, cuts, burns, splinters, and so forth, which do not ord
narily require medical care) even though provided by a physician or registered profe
sional personnel.
4. LOST WORKDAYS
The number of days the employee would have worked but could not because <
occupational injury or illness. The number of lost workdays should not include t}
day of injury. The number of days includes all days (consecutive or not) on whicl
because of the injury or illness:
a. the employee would have worked but could not, or
b. the employee was assigned to a temporary job, or
c. the employee worked at a permanent job less than full time, or
d. the employee worked at a permanently assigned job but could not perf orn
all duties normally assigned to it.
For employees not having a regularly scheduled shift, i.e., certain truck driver
construction workers, part-time employees, etc., it may be necessary to estimate tr
number erf lost workdays, Estimates of lost workdays shall be based on prior work histoi
of the employee AND days worked by employees, not ill or injured, working in tr
department and/or occupation of the ill or injured employee.
CHAP 3 Appendix 3-A TN 3
1-8-76
34
-------
INSTRUCTIONS FOR
COMPLETING LOG OF
FEDERAL OCCUPATIONAL
INJURIES AND ILLNESSES
(OSHA FORM NO. 100F)
Column 1—CASE OR FILE NUMBER
Any number may be entered which will facilitate comparison
with supplementary records.
Column 2—DATE OF INJURY OR ILLNESS
For occupational injuries enter the date of the work accident
which resulted in injury. For occupational illnesses enter the
date of initial diagnosis of illness, or, if absence occurred
before diagnosis, the first day of the absence in connection
with which the case was diagnosed.
Column 3—EMPLOYEE'S NAME
Column 4-OCCUPATION
Enter the occupational title of the job to which the employee
was assigned at the time of injury-oj: illness. In the absence of
a formal occupational title, enter a brief description of the
duties of the employee.
Column 5—DEPARTMENT
Enter the name of the department to which employee was
assigned at the time of injury or illness, whether or not em-
ployee was actually working in that department at the time.
In the absence of formal department titles, enter a brief de-
scription of normal workplace to which employee is assigned.
Column 6—NATURE OF INJURY OR ILLNESS AND PART(S)
OF BODY AFFECTED
Enter a brief description of the injury or illness and indicate
the part or parts of body affected. Where entire body is af-
fected, the entry "body" can be used.
Column 7—INJURY OR ILLNESS CODE
Enter the one code which most accurately describes the nature
of injury or illness. A list of codes appears at the bottom of the
log. A more complete description of occupational injuries and
illnesses appears below in "definitions."
Column 8—FATALITIES
If the occupational injury or illness resulted in death, enter date
of death.
Column 9—LOST WORKDAY CASES
Enter a check for each case which involves days away from
work, or days of restricted work activity, or both. Each lost
workday case also requires an entry in column 9A or column
9B, or both.
Column 9A-LOST WORKDAYS—DAYS AWAY FROM
WORK
Enter the number of workdays (consecutive or not) on which
the employee would have worked but could not •.•cause of
occupational injury or illness. The number of lost workdays
should not include the day of injury or onset of illness or any
days on which the employee would not have worked even
though able to work.
NOTE: For employees not having a regularly scheduled shift,
i.e., certain truck drivers, construction workers, part-time
employees, etc., it may be necessary to estimate the number of
lost workdays. Estimates of lost workdays shall be based on
prior work history of the employee and days worked by em-
ployees, not ill or injured, working in the department and/or
occupation of the ill or injured employee.
Column 9B—LOST WORKDAYS—DAYS OF RESTRICTED
WORK ACTIVITY
Enter the number of workdays (consecutive or not) on which
because of injury or illness:
I) the employee was assigned to another job on a temporary
basis,
2) the employee worked at a permanent job less than full time,
or
3) the employee worked at a permanently assigned job but
could not perform all duties normally connected with it.
The number of lost workdays should not include the day of
injury or onset of illness or any days on which the employee
would not have worked even though able to work.
Column 10—NONFATAL CASES WITHOUT LOST WORK-
DAYS <"
Enter a check in Column 10 for all cases of occupational injury
or illness, which did not involve fatalities or lost workdays but
did result in:
—Transfer to another job or termination of employment, or
—Medical treatment, other than first aid, or
—Diagnosis of occupational illness, or
— Loss of consciousness, or
—Restriction of work or motion.
Column ll— TRANSFER TO ANOTHER JOB OR TERMINA-
TION OF EMPLOYMENT WITHOUT LOST WORK-
DAYS
If ..ie check in Column 10 represented a transfer to another
job or termination of employment with no lost workdays,
enter another check in Column 11.
INITIALING REQUIREMENT
Each line entry regarding an occupational injury or illness
must be initialed in the right hand margin by the person respon-
sible for the accuracy of the entry. Changes in an entry also
must be initialed in the affected column.
CHANGES IN EXTENT OF OR OUTCOME OF INJURY OR
ILLNESS
If there is a change in an occupational injury or illness case
which affects entries in Columns 9, 10, or 11, the first entry
should be lined o«t and a new entry made. For example, if an
'injured employee at first required only medical treatment but
later lost workdays, the check in Column 10 should be lined out
and the number of lost workdays entered in Column 9.
In another example, if an employee with an occupational
illness lost workdays, returned to work, and then dies of the
illness, the workdays noted in Column 9 should be lined out
and the date of death entered in Column 8.
An entry may be lined out if later found to be a nonoccu-
palional injury or illness.
Appendix 3-B
1
TN 3
1-8-76
OfO 006-074
-------
OSHA NO. 1001-
LJ .-i
1 M
oo
1 to
LOG OF FEDERAL OCCUPATIONAL INJURIES AND ILLNESSES
RECORDABLE CASES: You ••• r*quired to record in.oni.aUo.. about: •vary *ccupaUoa*l death.
•very nonfat*, occupational illness; and those nonfat at occupational injuries which involve one or
more of the following: loss of workdays, loss of consciousness, restriction of work or atot.oa. trans-
fer to another job, or medical treatment (other than first aid).
More complete definition* appear on the ether sl
OCCUPATION
(Efltar regular |ok till*, not
an»«t of UlnoM.)
DEPARTMENT
• hick Ih. o».olor.o !•
,.,,U.1, ...I., .J.I
IS) .
DESCRtPT ON OF INJURY OR ILLNESS
Notwrt of Injurr of lllri«B» onrf P«rl{«) ol
BOOT A(Uct*d
Canlocl avnnali >» •« b«Ml hanvi
Intury or
MlntKB
Codo
ol Mo*.
EXTENT OF AND OUTCOME OF CASES
DEATHS
lEniar
•era of
•»0*.l
""lit*' '''
j
LOST WORKDAY CASES
Enter e chect
it cat* .«v*tved
lost overhtJeyt.
LOST WORKDAYS
of dor* AWAY
f ROM WORK
or .line'.*.'
CfA)
.
Etta* ftumbar
of d«y* t-f
RESTRICTED
KORtC ACTIVITY
due to i«jury «r
(VB)
*
NON FATAL
CASES WITHOUT
LOST
WORKDAYS
1 Enter • check if
8 or 9 but th«
cef* ii receraaUe,
•• aef.nea ehove.;
(10)
TERMINATIONS
(£•>'•> a cK*cii if
•tiB «rnr in coiunn*
e ••nrifiet-o" or
1
rf federal CitaMi•*«**(
10 * All occupational injuries
21 Occupolionol tltiA diseates or disotders
22 Dw»i di»e"te» »f *Ke lungs (pnewmoconiotes) c
23 Resplrotery condition* duo to tonic agents
IlliMss Codes
25 Disorders du* to physical agents (other than
Mxie materials)
26 Disorders due to repealed trauma
24 Poisoning (Systemic effects ef taxi« materials) 29 .All other occupational illnesse
-------
DEFINITIONS OF TERMS
FOR USE IN RECORDING
FEDERAL OCCUPATIONAL
INJURIES AND ILLNESSES
OCCUPATIONAL INJURY is any injury such as a cut, frac-
ture, sprain, amputation, etc., which results from a work accident
or from exposure in the work environment.
OCCUPATIONAL ILLNESS of an employee is any abnormal
condition or disorder, other than one resulting from an occupa-
tional injury, caused by exposure to environmental factors asso-
ciated with his employment. It includes acute and chronic illnesses
or diseases which may be caused by inhalation, absorption, inges-
tion, or direct contact, and which can be included in the categories
listed below.
The following listing gives the categories of occupational
illnesses and disorders that will be utilized for the purpose of
v classifying recordable illnesses. The identifying codes are those to
be used in Column 7 of the log. For purposes of information,
examples of each category are given. These are typical examples,
however, and are not to be considered to be the complete listing of
the types of illnesses and disorders that are to be counted under
each category.
(21) Occupational Skin Diseases or Disorders
Examples: Contact dermatitis, eczema, or rash caused by
primary irritants and sensitizers or poisonous plants; oil
acne; chrome ulcers; chemical burns or inflammations;
etc.
(22) Dust Diseases of the Lungs (Pncumoconioses)
Examples: Silicosis, asbestosis, coal worker's pneumo-
coniosis, byssinosis, and other pneumoconioses.
(23) Respiratory Conditions Du.e to Toxic Agents
Examples: Pneumonitis, pharyngitis, rhinitis or acute con-
gestion due to chemicals, dusts, gases, or fumes; farmer's
lung; etc.
(24) Poisoning (Systemic Effects of Toxic Materials)
Examples: Poisoning by lead, mercury, cadmium, arsenic,
or other metals, poisoning by carbon monoxide, hydrogen
sulfide or other gases; poisoning by benzol, carbon tetra-
chloride, or other organic solvents; poisoning by insecti-
cide sprays such as parathion, lead arsenate; poisoning
by other chemicals such as formaldehyde, plastics and
resins, etc.
(25) Disorders Due to Physical Agents (Other Than Toxic
Materials)
Examples: Heatstroke, sunstroke, heat exhaustion and
other effects of environmental heal; freezing, frostbite and
effects of exposure to low temperatures; caisson disease;
effects of ionizing radiation (isotopes. X-rays, radium);
effects of nonionizing radiation (welding flash, ultraviolet
rays, microwaves, sunburn), etc.
(26) Disorders Due to Repeated Trauma
Examples: Noise-induced hearing loss; synovitis, teno-
synovitis, and bursitis; Raynaud's phenomena; and other
conditions due fo repeated motion, vibration or pressure.
(29) All Other Occupational Illnesses
Examples: Anthrax, brucellosis, infectious hepatitis,
malignant and benign tumors, food poisoning, histo-
plasmosis, coccidioidomycosis, etc.
RECORDABLE OCCUPATIONAL INJURIES AND ILL-
NESSES are any occupational injuries or illnesses which result
in: . i
1) FATALITIES, regardless of the time between the injury/
and death, or the length of the illness; or /
2) LOST WORKDAYS CASES, other than fatalities that
result in lost workdays; or
3) NONFATAL CASES WITHOUT LOST WORKDAYS,
which result in transfer to another job or termination of
employment, or require medical treatment (as defined
below), or involve loss of consciousness or restriction of
work or motion. This category also includes any diag-
nosed occupational illnesses which are reported to the
Agency but are not classified as fatalities or lost workday
cases.
MEDICAL TREATMENT includes treatment administered
by a physician or by registered professional personnel under the
standing orders of a physician. Medical treatment does NOT
include first aid treatment (one-time treatment and subsequent
observation of minor scratches, cuts, burns, splinters, and so
forth, which do not ordinarily require medical care) even though
provided by a physician or registered professional personnel.
ESTABLISHMENT: A single physical location where busi-
ness is conducted or where services or industrial operations are
performed. (For example: warehouse, or central administrative
office.) Where distinctly separate activities are performed at a
single physical location (such as contract construction activities
operated from the same physical location as a lumber yard), each
activity shall be treated as a separate establishment.
Agencies engaged in activities such as agriculture, construc-
tion, transportation, communications, and electric, gas and sani-
tary services, which may be physically dispersed, records may be
maintained at a place to which employees report each day.
Records for personnel who do not primarily report to work at a
single establishment, such as traveling technicians, engineers, etc.,
shall be maintained at the location from which they are paid
or the base from which personnel operate to carry out their
activities.
WORK ENVIRONMENT is comprised of the physical loca-
tion, equipment, materials processed or used, and the kinds of
operations performed by an employee in the performance of his
work, whether on or off the Agency's premises.
f 3
•8-76
Appendix 3-B
3
-------
-------
List of Reporting Units, Reviewing Authorities
and Officers-In-Charge of Reporting Units
I. Regional Organization
Officers-in-Charge
Reporting Unit Reviewing Authority of Reporting Unit
1. Regional Office Regional Administrator Regional Administrator
Region I Region I Region I
JFK Federal Bldg.
Boston, Mass. 02203
(Includes all Region I facilities in the vicinity of Boston, Mass.)
2. Regional Office Regional Administrator Regional Administrator
Region II Region II Region II
FOB 26 Federal Plaza
New York, N.Y. 10007
(Includes all Region II facilities in the New York City Metropolitan area)
3. Central Regional Lab Regional Administrator Director,
Woodbridge Ave. Region II Surveillance and
Edison, N.J. 08817 Analysis Division
4. Associated Regional Regional Administrator Director,
Laboratory Region II Rochester Field Office
U. of Rochester
Rochester, N.Y. 14627
5. San Juan Regional Administrator Director,
Field Office Region II San Juan Field Office
Santurce, P.R. 00908
6. Regional Office Regional Administrator Regional Administrator
Region III Region III Region III
Curtis Bldg.
6th and Walnut
Phila., Pa. 19106
(Includes all Region III facilities in the Philadelphia Metropolitan
area and Region III Consumer Safety Officers).
7. Annapolis Field Office Regional Administrator Director,
Riva Road Region III Annapolis Field Office
Annapolis, Md. 21401
8. Wheeling Field Office Regional Administrator Director,
303 Methodist Bldg. Region III Wheeling Field Office
Wheeling, W. Va. 26003
Appendix
-------
Officer-in-Charge
Reporting Unit s Reviewing Authority of Reporting Unit
9. Regional Office Regional Administrator Regional Administrator
Region IV Region IV Region IV
1421 Peachtree St.,N.E.
Atlanta, Georgia 30309
(Includes all Region IV facilities in the Atlanta Metropolitan area
and Region IV Consumer Safety Officers)
10. Regional Lab. Regional Administrator Director,
College Sta. Road Region IV Surveillance and
Athens, Ga. 30601 Analysis Division
(Includes Bailey Road Annex and Mississippi Test Facility, Bay St. Louis., Miss.39520)
11. Regional Office Regional Administrator Regional Administrator
Region V Region V Region V
230 S. Dearborn St.
Chicago, 111. 60604
(Includes all Region V facilities in the Chicago Metropolitan area)
12. Indiana District Office Regional Administrator Director,
Heidelback and Diamond Region V Ind. District Office
Ave. Expway
Evansville, Ind. 47711
13. Minn.-Wise. Dist. Office Regional Administrator Director,
7401 Lyndale Ave. So. Region V Minneapolis Dist. Office
Minneapolis, Minn. 55423
14. Mich.-Ohio Dist. Office Regional Administrator Director,
21929 Lorain Road Region V Ohio Dist. Office
Cleveland, Ohio 44126
15. Regional Office Regional Administrator Regional Administrator
Region VI Region VI Region VI
16QQ Patterson Ave.
Dallas, Texas 75201
(Includes all Region VI Dallas-Ft. Worth area facilities and Region
VI Consumer Safety Officers)
16. Regional Laboratory Regional Administrator Director,
Bldg. C-Monterey Park Region VI Surveillance and
Plaza Analysis Division
6600 Hornwood Drive
Houston, Texas 77036
TN 3 Appendix 3-C
1-8-76 2
-------
Officer-in-Charge
Reporting Unit Reviewing Authority of Reporting Unit
17- Surveillance and Regional Administrator Supervisor,
Analysis Lab. Region VI Surveillance and
Mississippi Test Facility Analysis Lab.
Bay St. Louis, Miss. 39520
(Includes Emergency Response Team based at MTF)
18. Regional Office Regional Administrator Regional Administrator
Region VII Region VII Region VII
1735 Baltimore Ave.
Kansas City, Mo. 64108
(Includes all Kanses City Metropolitan area facilities, all Region VII
Consumer Safety Officers, all Satellite Regional facilities, and
Regional State Liaison Offices)
19. Regional Office Regional Administrator Regional Administrator
Region VIII Region VIII Region VIII
Lincoln Tower Bldg.
1860 Lincoln Street
Denver, Colorado 80203
(Includes all Regional Denver Metropolitan area and Denver Federal Center
facilities, Regional VIII Consumer Safety Officers, and Regional State
Liaison Offices).
20. Regional Office Regional Administrator Regional Administrator
Region IX Region IX ' Region IX
100 California St.
San Francisco, Calif.
(Includes all Regional San Francisco Metropolitan area facilities and all
other facilities under the jurisdiction of Region IX)
21. Regional Office Regional Administrator Regional Administrator
Region X Region X Region X
1200 6th Ave.
Seattle, Wash. 98101
(Includes Seattle area Regional facilities, Washington operations offices,
State Liaison Offices, and other facilities under the jurisdiction of
Region X with the exception of Anchorage, Alaska.
22. Alaska Operations Regional Administrator Director,
Office Region X Alaska Operations
Federal Building Office
605 4th Ave.
Anchorage, Alaska 99501
Appendix 3-C ™ 3
o 1—o—/O
-------
II. Administrator
Reporting Unit
23. Office of the
Administrator
(Wash. Hq.)
III. Assistant Administrator for
Planning and Management
Reporting Unit
24. Office of the Assistant
Administrator for
Planning & Management
(Wash. Hq.)
25. Office of Administration
(Wash. Hq.)
26. Office of Administration
Yorktowne Mall
2634 Chapel Hill Blvd.
Durham, N.C. 27707
(Includes all RTF area Office
27. Office of Planning and
Evaluation
(Wash. Hq.)
28. Office of Resources
Management
(Wash. Hq.)
IV. Assistant Administrator for
Enforcement
Reporting Unit
29. Office of the Asst. Adm.
for Enforcement
(Wash. Hq.)
30. Office of General
Enforcement
(Wash. Hq.)
Reviewing Authority
Deputy Administrator
Reviewing Authority
Asst. Adm. for
Planning & Management
Asst. Adm. for
Planning & Management
Asst. Adm. for
Planning & Management
Office-in-Charge
of Reporting Unit
Executive Officer,
Office of the
Administrator
Officer-in-Charge
of Reporting Unit
Asst. Adm. for
Planning & Mgmt.
Deputy Asst. Adm.
for Administration
Director of
Administration, RTF
of Administration facilities)
Asst. Adm. for
Planning & Management
Deputy Asst. Adm.
for Planning & Eval.
Asst. Adm. for
Planning & Management
Reviewing Authority
Asst. Adm. for
Enforcement
Asst. Adm. for
Enforcement
Deputy Asst. Adm.
for Resources
Management
Off icer-in-Charge
of Reporting Unit
Deputy Asst. Adm.
Enforcement
Deputy Asst. Adm.
for General
Enforcement
TN 3
1-8-76
Appendix 3-C
4
-------
Reporting Unit
31. Office of Water
Enforcement
(Wash. Hq.)
32. National Field Investi.
Center, Building 53
Box 25227
Denver Federal Center
Denver, Colo. 80225
V. Assistant Administrator for
Water and Hazardous Materials
Reviewing Authority
Asst. Adm. for
Enforcement
Asst. Adm. for
Enforcement
Of£icer-in-Charge
of Reporting Unit
Deputy Asst. Adm.
for Water
Enforcement
Director,
NFIC Denver
33. Office of the Asst. Adm.
for Water and Hazardous
Materials
(Wash. Hq.)
34. Office of Pesticides
Programs
(Wash. Hq.)
35. Pesticides Lab.
A.R.C.
Beltsville, Md. 20705
36. Plant Bio. Lab.
3320 Orchard Ave.
Corvallis, Oregon
97330
3 7. Pesticides Monitoring Lab.
Miss. Test Facility
Bay St. Louis, Miss
39520
38. Office of Toxic
Substances
(Wash. Hq.)
39. Office of Water Planning
and Standards
(Wash. Hq.)
Asst. Adm. for Water
and Hazardous Mat.
Asst. Adm. for Water
and Hazardous Mat.
Asst. Adm. for Water
and Hazardous Mat.
Asst. Adm. for Water
and Hazardous Mat.
Asst. Adm. for Water
and Hazardous Mat.
Asst. Adm. for Water
and Hazardous Mat.
Asst. Adm. for Water
and Hazardous Mat.
Asst. Adm. for
Water and
Hazardous Mat.
Deputy Asst. Adm.
for Pesticides
Programs
Chief, Chem. and
Bio. Inv. Branch
Biological Methods
Coordinator, Plant
Biology Laboratory,
Corvallis
Manager, Pest.
Monitoring Lab.
Director, Office
of Toxic Substances
Deputy Asst. Adm.
for Water Planning
and Standards
Appendix 3-C
5
TN 3
1-8-76
-------
Reporting Unit
40. Office of Water Program
Operations
(Wash. Hq.)
41. Office of Water Supply
(Wash. Hq.)
VI. Assistant Administrator for
Air and Waste Management
Reporting Unit
42. Office of the Asst.
Mm. for Air and
Waste Management
(Wash. Hq.)
43. Office of Air Quality
Planning & Standards
411 W. Chapel Hill St.
Durham, N.C. 28801
44.
45.
Office of Mobile Source
Air Pollution Control
(Wash. Hq.)
Reviewing Authority
Asst. Adm. for Water
and Hazardous Mat.
Asst. Adm. for Water
and Hazardous Mat.
Reviewing Authority
Asst. Adm. for Air
and Waste Management
Asst. Adm. for Air
and Waste Management
Asst. Adm. for Air
and Waste Management
Asst. Adm. for Air
and Waste Management
Mobile Source Air
Pollution Control Lab.
2565 Plymouth Road
Ann Arbor, Mich. 48105
(Includes Office Annex at 2929 Plymouth Road)
46. Office of Noise Abatement
and Control
(Wash. Hq.)
47. Office of Radiation
Programs
(Wash. Hq.)
48. Office of Radiation
Programs, Las Vegas
Facility
P.O. Box 15027
Las Vegas, Nev. 89114
Asst. Adm. for Air
and Waste Management
Asst. Adm. for Air
and Waste Management
Asst. Adm. for Air
and Waste Management
Officer-in-Charge
of Reporting Unit
Deputy Asst. Adm.
for Water Program
Operations
Deputy Asst. Adm.
for Water Supply
Officer-in-Charge
of Reporting Unit
Asst. Adm. for
Air & Waste Mgmt.
Deputy Asst. Adm.
for Air Quality
Planning & Standards
Deputy Asst. Adm.
for Mobile Source
Air Pollution Control
Director, Mobile
Source Air Pollution
Control Laboratory
Deputy Asst. Adm.
for Noise Abatement
and Control
Deputy Asst. Adm.
for Rad. Programs
Director, Office of
Radiation Programs,
Las Vegas Facility
TN 3
1-8-76
Appendix 3-C
6
-------
Reporting Unit
49. Eastern Env. Radiation
Facility
1890 Federal Drive
Montgomery, Ala. 36101
50. Office of Solid Waste
Management Programs
(Wash. Hq.)
VII. Assistant Administrator for
Research, and Development
Reporting Unit
51. Office of the Asst.
Adm. for Res. & Dev.
(Wash. Hq.)
52. Office of Air, Land,
and Water Use
(Wash. Hq.)
53. Office of Energy,
Minerals, & Industry
(Wash. Hq.)
54. Office of Health and
Ecological Effects
(Wash. Hq.)
55. Office of Monitoring
and Technical Support
(Wash. Hq.)
56. Environmental Res. Lab.
West Kingston
P.O. Box 277
West Kingston, R.I.
02892
Reviewing Authority
Asst. Adm. for Air
and Waste Management
Asst. Adm. for Air
and Waste Management
Reviewing Authority
i
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Off ic er-in-Charge
of Reporting Unit
Director
EERF
Deputy Asst. Adm.
for Solid Waste
Mgmt. Programs
Officer-in-Charge
of Reporting Unit
Asst. Adm. for
Res. and Dev.
Deputy Asst. Adm.
for Air, Land and
Water Use
Deputy Asst. Adm.
for Energy,
Minerals, and Ind.
Deputy Asst. Adm.
for Health & Ecol.
Effects
Deputy Asst. Adm.
for Monitoring &
Tech. Support
Director, ERL
West Kingston
57. Environmental Res. Lab.
Narragansett, R.I. Q2880
53 . Edison Ind. Envir.
Research Laboratory
Woodbridge Ave.
Edison, N.J. 08817
Asst. Adm. for Res.
and Development
Asst. Adm. :or Res.
and Development
Director, ERL
Narragansett
Director, Edison
Ind. Envir. Res. Lab.
59. Mich. Dist. Office
9311 Groh. Road
Grosse He, Mich. 48138
Regional Administrator
Region V
Appendix 3-C
7
Director,
Mich. Dist. Office
TN 3
1-8-76
-------
Reporting Unit
60. Mine Drainage Pollution
Control Project
P.O. Box 5555
Riverville, W. Va.
61. Blue Plains Pilot Plant
5000 Overlook Ave.,S.W.
Washington, D.C. 20032
Reviewing Authority
Asst. Adm. For Res.
and Development
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
62. Environmental Monitoring
and Support Laboratory
Research Triangle Park,
N.C. 27711
(Includes all R.T.P. area EMSL facilities)
Asst. Adm. for Res.
and Development
63. Industrial Environmental
Research Lab. Research
Triangle Park, N.C.
27711
(Includes all R.T.P. area IERL facilities)
64. Environmental Sciences
Research Laboratory
Research Triangle Park,
N.C. 27711
(Includes all RTF area ESRL facilities
Asst. Adm. for Res.
and Development
65. Health Effects Res.
Lab. Res. Triangle Park,
N.C. 27711
(Includes all RTF area-HERL facilities)
Asst. Adm. for Res.
and Development
66. Bears Bluff Field Station
Box 368
Johns Island, S.C. 29455
67. Envir. Research Lab.
College Sta. Road
Athens, Georgia 30601
68. Envir. Research Lab.
Sabine Island
Gulf Breeze, Fla. 32561
69. Envir. Research Lab.
6115 Condon Blvd.
Duluth, Minn. 55804
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Officer-in-Charge
of Reporting Unit
Director, MDPCP
Dir, Blue Plains
Pilot Plant
Director, EMSL
R.T.P.
Director, IERL
R.T.P.
Director, IERL,
R.T.P.
Director, HERL
R.T.P.
Chief, Bears
Bluff Field Sta.
Director, ERL
Athens
Director, ERL
Gulf Breeze
Director, ERL
Duluth
TN 3
1-8-76
Appendix 3-C
8
-------
Reporting Unit
70. Grosse lie Laboratory
9311 Groh. Road
Grosse He, Mich. 48138
71. Lebanon Pilot Plant
Route 2, Box 7-A,
Lebanon, Ohio 45036
72.
73.
74.
Newtown Fish Toxicology
Station
3411 Church Street
Cincinnati, Ohio 45244
Reviewing Authority
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Environmental Monitoring
and Support Laboratory
Cincinnati, Ohio 45268
(Includes all Cincinnati area EMSL facilities)
Asst. Adm. for Res.
and Development
Industrial Environ.
Research Laboratory
Cincinnati, Ohio 45268
(Includes all Cincinnati area IERL facilities)
Officer-in-Charge
of Reporting Unit
Director,
Grosse He Lab.
Chief, Lebanon
Pilot Plant
Chief, Newtown
Fish Toxicology
Station
Director, EMSL,
Cincinnati
Director, IERL
Cincinnati
75. Municipal Environmental Asst. Adm. for Res.
Research Laboratory and Development
Cincinnati, Ohio 45268
(Includes all Cincinnati area MERL facilities)
76. Health Effects Res. Lab. Asst. Adm. for Res.
Cincinnati, Ohio 45268 and Development
(Includes all Cincinnati area HERL facilities)
77. Ely Field Station
222 W. Conan St.
Ely, Minn. 55731
78. Thermal Water Poll. Study
Northern State Power Co.
Monticello, Minn. 55362
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Asst. Adm. for Res.
and Development
Director, MERL
Cincinnati
Director, HERL
Cincinnati
Chief, Ely
Field Station
Chief, Thermal
Water Poll. Study
Director, EMSL
Las Vegas
79. Environmental Monitoring
and Support Laboratory
P.O. Box 15027
Las Vegas, Nev. 89114
(Includes all Las Vegas area EMSL facilities and the Nevada Test Site Farm)
Appendix 3-C
9
TN 3
1-8-76
-------
Officer-in-Charge
Reporting Unit Reviewing Authority of Reporting Unit
80. Robert S. Kerr Ass. Adm. for Res. Director, Robert
Envir. Research Lab. and Development S. Kerr Envir.
Ada Research Park Research Lab.
Ada, Oklahoma 74820
81. Environmental Res. Lab. Asst. Adm. for Res. Director, ERL
200 S.W. 35th St. and Development Corvallis
Corvallis, Oregon 97330
(Includes all Corvallis and Newport area facilities under the jurisdiction
of the Assistant Administrator for Research and Development)
82. Arctic Environmental Asst. Adm. for Res. Director, AERL
Research Laboratory and Development College
College, Alaska 99701
83. Field Studies Section Asst, Adm. for Res. Chief, 'Wenatchee
1801 Springfield Ave. and Development Field Studies
Wenatchee, Wash. 98801 Section
Appendix 3-c
TN 3 10
1-8-76
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