NOTICE OF CONDITIONS UNDER WHICH THIS INFORMATION IS COLLECTED AND USED
Pursuant to Section 3(e)(3) of the Privacy Act of 1974 (Public Law 93-579), the individual furnishing information on this form is hereby advised as follows:
The Authority for solicitation of the information is Section 19 of the Occupational Safety and health Act of 1970 (Public Law 91-596);5 U.S.C. 7902; 29 CFR 1960; Executive Order No. 12196 (February 26, 1980); and 28 U.S.C. 2671-80.
The principal purpose for which the information is intended to be used is to provide summary data of injury and property loss information for analytical purposes to be used in establishing programs to reduce or eliminate loss producing problem areas.
The routine uses of the information are: (1) To Provide quarterly listings of fatalities, disabling injuries, illnesses and property damage to the Department of Labor, in compliance with 29 CFR 1960.69.(2) Transfer to the U.S. Department of Justice in the event of litigation involving the records or the subject matter of the records. (3) Transfer, in the event there is indicated a violation or potential violation of a statute, regulation, whether civil, criminal or regulatory in nature, to the appropriate agency or agencies, whether federal, state, local or foreign, charged with the responsibility of investigation or prosecution of such violation or charged with enforcing or implementing the statute, rule, regulation, order or license violated or potentially violated.
The effect on the individual of not providing all or any part of the requested information may be to render impossible or to delay the Department's documenting the injury and/or property loss. Every effort will be made to obtain the factual information relating to an incident from other sources, should the individual involved refuse to provide the requested information.