Mandatory Reporting of Injuries/ Illnesses to VOSHA Online Form

Mandatory Reporting of Injuries/ Illnesses to VOSHA Online Form
Basic Requirements -1904.39(a):

Within eight (8) hours after the death of any employee as a result of a work-related incident, you must report the fatality to the Occupational Safety and Health Administration (OSHA), U.S. Department of Labor or the Vermont Occupational Safety and Health Administration (VOSHA).
Within twenty-four (24) hours after the in-patient hospitalization of one or more employees or an employee’s amputation or an employee’s loss of an eye, as a result of a work-related incident, you must report the in-patient hospitalization, amputation, or loss of an eye to OSHA or VOSHA.
You must report the fatality, in-patient hospitalization, amputation, or loss of an eye using one of the following methods:
1. By telephone or in person to the OSHA Area Office that is nearest to the site of the incident.
2. By Telephone to the OSHA toll-free central telephone number, 1-800-321-OSHA (1-800-321-6742).
3. By electronic submission using the form below.

Establishment Name

Number of Employees at Establishment?

Type of Event

Inpatient Hospitalization

Amputation

Loss of Eye(s)

Fatality

Other

Has this injury or illness occurred before?

Yes

Number of Employees Injured

Please provide FULL NAME(S) for injured employee(s)

Please provide FULL NAME(S) for injured employee(s)
	Please provide FULL NAME(S) for injured employee(s)	Item weight

more items

Please provide TITLE(S) for injured employee(s)

Please provide TITLE(S) for injured employee(s)
	Please provide TITLE(S) for injured employee(s)	Item weight

more items

Telephone of Injured Employee(s)

Telephone of Injured Employee(s)
	Telephone of Injured Employee(s)	Item weight

more items

Report submitted by:

First Name

Last Name

Telephone

Address

Street Address

Address Line 2

City

State

Zip Code

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