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Mandatory Reporting of Injuries/ Illnesses to VOSHA Online Form
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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:
By telephone or in person to the OSHA Area Office that is nearest to the site of the incident.
By Telephone to the OSHA toll-free central telephone number, 1-800-321-OSHA (1-800-321-6742).
By electronic submission using the form below.
Establishment Name
Number of Employees at Establishment?
Location of the work related incident
Date of the work related incident
Time of the work related incident
Type of Event
Type of Event
Inpatient Hospitalization
Amputation
Loss of Eye(s)
Fatality
Other
Has this injury or illness occurred before?
Yes
No
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
Add more items
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
Add more items
more items
Please provide a description of the incident and details of how the injury occured
Telephone of Injured Employee(s)
Telephone of Injured Employee(s)
Telephone of Injured Employee(s)
Item weight
Add more items
more items
Report submitted by:
First Name
Last Name
Last Name
Email
Telephone
Address
Street Address
Address line 2
Address Line 2
City
City
State
State
Zip
Zip Code
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