Chris Johnson, Index

U.S. Department of Agriculture

Departmental Administration

Human Resources Management

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Fatality and Serious Incident Report

Complete all applicable information on this form and fax to: Safety and Health Management Division, (202) 720-9686 within 8 hours of incident.

Report Date:

Report Time (EST):

Reporting Agency:

Name and Job Title of Reporting Official:

Telephone Number:

Incident Date:

Incident Time:

Date Reported to OSHA:

Time Reported to OSHA:

Name of OSHA Official Notified:

EMPLOYEE FATALITY INFORMATION

Name and Job Title:

Date of Birth:

Social Security Number:

Incident Location:

On-Site Point of Contact:

Telephone Number:

Description of Incident/Cause of Death:

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