Quality
of Work Life Division
Fatality
and Serious Incident Report
Complete all applicable information and fax to:
Quality of Work Life Division, (202) 720-9686 within 8 hours of
incident.
Report Date: |
Report Time (EST): |
Reporting Agency: |
Name and Job Title of Reporting Official: |
Telephone Number: |
Incident Date: |
Incident Time: |
Date Reported to OSHA: |
Time Reported to OSHA: |
Name of OSHA Official Notified: |
||
EMPLOYEE FATALITY INFORMATION |
||
Employee’s Name |
||
Date of Birth |
Last Four Digits of Social Security Number: |
|
Incident Location: |
||
On-Site Point of Contact: |
Telephone Number: |
|
For more information, please contact
your agency safety and
health program coordinator.
Home | USDA | Office of Human Capital Management|
Back to Departmental Administration
| Quality of Work Life Division