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.

Employer Name

Total Number of Employees?

Did the incident occur at the employer's address or a jobsite?

Employer Address

Job Site

Type of Incident

Inpatient Hostpitalization

Amputation

Loss of Eye(s)

Fatality

Other…

Has this injury/illness occurred before?

Yes

Number of Employees Injured

Name, Position/Title, Phone, and Email for each injured employee

(First Name, Last Name, Title, Phone, Email)

Name, Position/Title, Phone, and Email for each injured employee
	Name, Position/Title, Phone, and Email for each injured employee	Item weight

more items

Report submitted by:

First Name

Last Name

Title/Position

Telephone

Address

Street Address

Address Line 2

City

State

Zip Code

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