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Please complete this report in the event of an on-the-job death, in the previous year to the present.

Date occurred _________________________

Time occurred ________________________

Information about Deceased:
Name:________________________________	Job Class/Title ________________________
Social Security Number _________________	Local Union Number ___________________

Information about Company:
Company Name ______________________________________________________________
Address _____________________________________________________________________
City _________________________________	State(Province)_________________________
Zip Code ______________
Type of Industry ______________________________________________________________
Bargaining Unit Size at company _________________________________________________

Reported By:

Name ______________________________________________________________________

Title _______________________________________________________________________

Cause of Death: (pick one)
__ Electrical	__ Inhalation of gas, specify ______________
__ Elevator/hoist conveyor	__ Stepped on
__ Explosive	__ Struck by:
__ Fall		__ Vehicle
__ Fire		__ Machine
__ Hand tool		__ Object
__ Handling objects, manual		__ Other, specify ________________
__ Heat	__ Striking against object
__ Poisoning	__ Vehicular accident:       __ Local Pickup&Delivery
__ Other, specify		__ Over-the-road
_______________________		__ Powered industrial truck
_______________________		__ Other, specify ________________
_______________________	__ Workplace Violence

                Notes: (Please provide details of the incident)PLEASE MAIL OR FAX TO:
IBT Safety and Health Department
25 Louisiana Ave, NW, Washington, DC 20001 Telephone: (202) 624-6960
Fax: (202) 624-8740