Serious Event Reporting Online Form

Items noted with an asterisk (*) are required in order to accept your submission.

Information about the location where the incident occured

*Name of Location (or Description)

Street Address 1

Street Address 2

*City

*State

*County

*Zip

GPS Coordinates

Information about the incident

*Date incident occurred

ex. mm/dd/yyyy

*Time incident occurred

ex. 2245

*What Happened? Additional Information

Number of Fatalities

Number of Hospitalizations

Employer Information

*Legal Business Name

Other Name

*Street Address 1

Street Address 2

*City

*State

Zip

Information for persons who OSHA can contact

Contact #1

*First name

*Last name

*Title

*Work Phone

Cell Phone

*Email Address

Contact #2

First name

Last name

Title

Work Phone

Cell Phone

Email Address

Information for Each of the Victims

*Victim First name

*Victim Last name

What was the employee doing just before the incident occurred? *What was the injury or illness? What object or substance directly harmed the employee?

Was there a fatality? Yes No

Was victim hospitalized? Yes No

Was there an amputation? Yes No

Was there the loss of an eye? Yes No

U.S. Department of Labor

Occupational Safety and Health Administration

Serious Event Reporting Online Form

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