Serious Event Reporting Online Form Information about the location where the incident occured Name of Location (or Description) * Address Line 1 * date_range access_time Address Line 2 date_range access_time City * date_range access_time State * Please select an option Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP Code * date_range access_time GPS Coordinates date_range access_time Information about the incident Date/Time incident occurred * Format: Jan/01/2020 1:00am date_range access_time What Happened * Additional Information Number of Fatalities date_range access_time Number of Hospitalizations date_range access_time Employer Information Legal Business Name * date_range access_time Other Name date_range access_time Address Line 1 * date_range access_time Address Line 2 date_range access_time City * date_range access_time State * Please select an option Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP Code * date_range access_time Information for persons who OSHA can contact Contact #1 First name * date_range access_time Last name * date_range access_time Title * date_range access_time Work Phone * date_range access_time Cell Phone date_range access_time Email Address * date_range access_time Contact #2 First Name date_range access_time Last Name date_range access_time Title date_range access_time Work Phone date_range access_time Cell Phone date_range access_time Email Address date_range access_time Information for Each of the Victims Victim First name * date_range access_time Victim Last name * date_range access_time 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? Please select an option Yes No Was victim hospitalized? Please select an option Yes No Was there an amputation? Please select an option Yes No Was there loss of an eye? Please select an option Yes No Information for Victim #2 Victim #2 First name date_range access_time Victim #2 Last name date_range access_time 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? Please select an option Yes No Was victim hospitalized? Please select an option Yes No Was there an amputation? Please select an option Yes No Was there loss of an eye? Please select an option Yes No Any additional victim information, please add below. Please upload any photos, reports, or documentation to supplement your report below File do NOT include any personal identification information, i.e. SSN, DLN, etc. in your documents Uploaded Files: navigate_nextContinue Your Session Is About To Expire Click continue to extend your session. Your Session Has Expired Close your browser or click OK to begin a new session.