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Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×

Appendix A

Recommendations

Recommendation A (Chapter 4): BLS and OSHA should collaborate to enhance injury and illness recording and the SOII to achieve more complete, accurate, and robust information on the extent, distribution, and characteristics of work-related injuries and illnesses and affected workers for use at the worksite and at national and state levels. As part of this effort, BLS should routinely collect detailed case and demographic data for injuries and illnesses resulting in job transfer or restricted-duty work. Furthermore, OSHA should amend its injury and illness recording requirements to collect information on race and ethnicity as well as on employment arrangement to identify vulnerable worker populations and risks that may be associated with the changing nature of work.

In the near term:

  • OSHA should make type of employment arrangement (e.g., traditional, independent contractor, temporary agency worker, and on-call worker) and race and ethnicity mandatory data elements on the OSHA Form 301, and BLS should incorporate this information into the SOII case and demographic data. OSHA should collaborate with BLS in determining the best approach to collecting this information (e.g., what questions should be included on Form 301).
  • BLS should routinely collect detailed case and demographic data for injuries and illnesses resulting in job transfer or restricted duty as well as those resulting in days away from work.
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
  • BLS should implement methods to aggregate SOII data over time to generate more robust and detailed state-level estimates.
  • OSHA and BLS should collaborate to enhance recordkeeping training for employers and BLS should evaluate approaches for providing initial information and ongoing feedback to data recorders in establishments enlisted to participate in the SOII both to improve the data quality and to promote employer use of data for prevention.

In the longer term:

  • BLS and OSHA should collaborate to determine the best way to collect injury and illness data across multiple employers working at single sites, and across enterprises with multiple establishments.
  • BLS should assess the feasibility and usefulness of extending collection of case and demographic data to all reported cases as automated approaches to coding SOII narratives are improved. Options for collecting such data should be evaluated in light of information that will be made available through the OSHA electronic reporting initiative.

Recommendation B (Chapter 4): NIOSH, working with the state occupational safety and health surveillance programs and across divisions within the agency, should develop a methodology and coordinated system for surveillance of both fatal and nonfatal occupational disease using multiple data sources. The data should be analyzed, interpreted, and presented regularly in a comprehensive public report. The data sources to be considered should include reporting by audiometric providers, disease registries (such as cancer and chronic renal failure), hospitals, laboratories, physicians, poison control centers, and health surveys as well as appropriate exposure databases. It is important that illness data collected by the states and NIOSH be analyzed and released in a timely manner. The data should be released in conjunction with BLS illness data in a manner that does not delay data released by BLS.

In the near term:

  • NIOSH should combine information from the existing focused occupational disease surveillance systems (e.g., ABLES, pesticide illness, silicosis surveillance, and NORMS) and mesothelioma from cancer registries and other relevant occupational health indicators to provide a more comprehensive annual report on the extent of occupational illness morbidity and mortality that can be released in conjunction with information from the SOII. Methods for extrapolating from available data to generate national estimates should be explored.
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
  • To enhance surveillance of occupational lung disease, NIOSH should require all B readers to report all chest radiographs interpreted to be positive for all types of pneumoconiosis.
  • Increased collaboration between NIOSH and CDC infectious disease surveillance programs, with improved collection of occupational information, will be important to improve documentation of endemic and epidemic infectious disease related to work.

In the longer term:

  • Gaps identified in the occupational illness surveillance system will need to be addressed through future developments that may involve
    • New or modified state regulations, requiring close coordination with the states, many of which have already promulgated reporting regulations.
    • Inference of occupational disease burden and trends that result from enhanced exposure assessment (Recommendation H, see Chapter 6).
    • Updating the list of occupational sentinel health events, establishing additional criteria for establishing a link between workplace exposures and common diseases.
  • Action on recommendations that address the inclusion of occupational information in medical records (see Recommendation J, see Chapter 7), federal health surveys and public health surveillance systems (Recommendation M, see Chapter 7), and automated coding of the industry and occupation information (see Recommendation L, see Chapter 7) will be important for ensuring the optimal implementation over time of this recommendation.

Recommendation C (Chapter 4): NIOSH should lead a collaborative effort with BLS, OSHA, the states, and other relevant federal agencies to establish and strengthen state-based OSH surveillance programs. This should be carried out as part of a national coordinated effort to monitor priority conditions, hazards, and exposures; to identify emerging workplace risks; and to facilitate prevention programs that address these concerns. Furthermore, this should be carried out with the full support of and assistance from other parts of HHS-CDC.

In the near term:

  • OSH Agency Collaboration Within States: NIOSH, BLS, and OSHA should actively encourage and promote collaboration among their programs in the states to reflect the national commitment to interagency effectiveness for OSH surveillance and leverage surveillance and prevention
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
  • expertise across agencies. This should include sharing data and taking advantage of unique state-level data sets and case-based surveillance capacities to identify and respond to emerging occupational safety and health hazards and conditions.
  • Public Health Agency Collaboration Within States: NIOSH and other CDC centers that support state-based surveillance and prevention activities should promote collaboration among their state-level programs to monitor and address public health problems of shared concern, such as violence, asthma, infectious disease, traffic safety, and health inequities among vulnerable population groups.
  • NIOSH should also
    • Explore and implement, as appropriate, alternative approaches to funding ongoing surveillance in the states as applied public health programs rather than research programs.
    • Foster increased coordination and communication between its intramural and extramural surveillance programs.
    • Encourage NIOSH-funded Education Research and Training Centers and Agricultural Health and Safety Centers to provide technical and research support to state surveillance programs in their regions as part of their required outreach and education core activity.

Recommendation D (Chapter 6): BLS should place priority on implementing its plan for a household survey of nonfatal occupational injury and illnesses (HSOII). With the assistance of NIOSH and Centers for Disease Control and Prevention (CDC), BLS should also expand this effort to include a periodic nationwide household survey to identify and track reports of occupational exposures and should determine how best to identify and track chronic work-related illnesses.

In the near term:

  • BLS should survey occupational injuries and acute illnesses (as in SOII) in a nationally representative sample of the entire working population including those who are self-employed or engaged in temporary contract work.

In the longer term:

  • To address the inadequacies of current surveillance tools, BLS should
    • Seek assistance from NIOSH to enhance the HSOII survey scope by assessing occupational exposures and risks in a manner like that used in the Eurofound Working Conditions Survey.
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
    • Questions should be included to capture exposure determinants and work characteristics with sufficient details on industry, occupation, work organizational characteristics, and working relationships in a way that supports the development of a flexible job exposure matrix and supports integration of newly available or ancillary data.
    • Seek assistance from NCHS and NIOSH to address currently inadequate information on chronic disease and work by determining whether self-report of illnesses and chronic conditions are best tracked by inserting occupational information into the NHIS or inserting chronic illness questions into the HSOII. Part of this consideration should include the determination of whether a sample of retirees and those not working due to disability should be part of the HSOII.
  • BLS should prepare and implement a specific plan for routine analysis, interpretation, and preparation of a report on the findings from the HSOII along with a plan for dissemination and appropriate database access by researchers and the public.

Recommendation E (Chapter 6): OSHA, in conjunction with BLS, NIOSH, state agencies, and other stakeholders, should develop plans to maximize the effectiveness and utility of OSHA’s new electronic reporting initiative for surveillance. These should include plans to provide ongoing analysis and dissemination of these data and to minimize duplication of reporting by employers.

In the near term:

  • To avoid duplicate reporting, OSHA and BLS should integrate data-collection efforts so that employers selected in the annual BLS sample for SOII but reporting electronically to OSHA need not make separate reports to BLS. This will require that a unified reporting form include requiring race and ethnicity in submitted case reports.
  • OSHA should provide timely and automatic feedback to employers that provides comparative information specific to the employer and others in that industry.
  • OSHA should develop a publicly available and easily searchable injury and illness database based on the electronic reports.

In the longer term:

  • OSHA and NIOSH should work with stakeholders to develop software and other tools and materials that facilitate further establishment-level analysis of injury data with specific attention to enabling effective use by employers as well as others to identify hazards and job-specific issues
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
  • for prevention. With experience from participants in this electronic reporting, OSHA should explore feasibility to expand electronic reporting to all employers required to maintain OSHA logs.

Recommendation F (Chapter 6): NIOSH with assistance from OSHA should explore and promote the expanded use of workers’ compensation data for occupational injury and illness surveillance and the development of surveillance for consequences of injury and illness outcomes, including return to work and disability.

In the near term:

  • NIOSH should organize an advisory group of workers’ compensation data experts to advise both the NIOSH Center for Workers’ Compensation Studies and interested states concerning their use of workers’ compensation data for surveillance and research.
  • NIOSH should encourage states to expand the use of workers’ compensation information beyond the Council of States and Territorial Epidemiologists (CSTE) occupational health indicators. Specifically, the agency should work through the state surveillance cooperative agreements to develop and enhance use of workers’ compensation data for state-based occupational injury and illness surveillance and prevention activities.

In the longer term:

  • NIOSH and OSHA should collaborate with states to pursue the development of surveillance systems that capture cost of work-related injury and illness, measure work-related disability and return-to-work outcomes, and assess the adequacy of benefits administered through workers’ compensation insurance programs.

Recommendation G (Chapter 6): HHS should designate industry and occupation as core demographic variables collected in federal health surveys, as well as in other relevant public health surveillance systems, and foster collaboration between NIOSH and other CDC centers in maximizing the surveillance benefits of including industry and occupation in these surveys and surveillance systems.

In the near term:

  • HHS should re-establish industry and occupation as core demographic variables in all federal health surveys.
  • CDC surveillance programs, as they proceed with their state part-
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
  • ners to streamline and harmonize data across systems, should work with NIOSH to identify appropriate processes for collecting and coding occupational and industry data.
  • NIOSH with assistance from CDC should explore and prioritize public health surveys that can be used to enhance occupational health surveillance objectives by collecting relevant occupational information.

In the longer term:

  • To promote proper analysis of surveillance data NIOSH should develop methods and training materials on approaches to basic as well as new and creative use of occupation and industry data and on the selection and use of appropriate labor force denominators.

Recommendation H (Chapter 6): NIOSH, in consultation with OSHA, should place priority on developing a comprehensive approach for exposure surveillance. The objective should be to build systematically a comprehensive and continuously updated database of risks and exposures that provides the basis for estimating work-related acute and chronic health conditions for prevention.

In the near term:

  • NIOSH should fully exploit the existing OSHA exposure databases by cleaning and integrating all available data sources to make them useful for surveillance purposes, taking proper account of the database limitations.

As an intermediate goal:

  • NIOSH, in collaboration with OSHA and other agencies as appropriate, should construct an integrated exposure database to include the multiple sources of exposure measurement data already available, specifically MSHA’s MSIS, Department of Energy and Nuclear Regulatory Commission personal exposure data, and relevant data from others conducting research with federal funds.

In the longer term:

  • NIOSH should link the integrated exposure database with the comprehensive survey data obtained in the recommended expanded HSOII (Recommendation D) and new data from any characterization of exposures from targeted industry-specific assessments.
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
  • NIOSH and OSHA should explore the feasibility of receiving employer-mandated exposure sample results after considering the reliability and quality of those measurements. The agencies should work with stakeholders to develop software and other tools and to facilitate establishment-level analysis of exposure data along with benchmarking.

Recommendation I (Chapter 7): NIOSH should coordinate with OSHA, BLS, and other relevant agencies to measure and report, on a regular basis, the economic and health burdens of occupational injury and disease at the national level. This report should also attempt to address the contribution of implemented interventions in reducing these burdens. The advantages of a regular, standard report on national economic burden of occupational injury and disease include:

  • focusing attention on the significant burden that already exists,
  • measuring progress over time in reducing those burdens and improving worker safety and health,
  • improving the allocation of existing resources to improve health outcomes, and
  • establishing priorities.

Research, such as to establish the fraction of disease and injuries attributable to occupational exposures, will be necessary to continually improve the quality of burden estimates that can be produced.

Recommendation J (Chapter 7): NIOSH should build and maintain a robust internal capacity in biomedical informatics applied to OSH surveillance.

In the near term:

  • Assess the need within the agency for expertise in biomedical informatics in the context of current and future demand, recognizing that it will be important to train informatics talent in OSH surveillance and then to work to retain talented individuals who develop knowledge at the intersection of the informatics discipline and OSH applications;
  • Create an organizational strategy for deploying and making optimal use of expertise in biomedical informatics to support the planning and conduct of OSH surveillance;
  • Develop a plan for hiring, including consideration of steps such as reaching out to academic programs, advertising in different venues, and offering internships; and
  • Develop a plan for retention, including opportunities for continuing education.
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×

Recommendation K (Chapter 7): NIOSH should work with the National Library of Medicine to incorporate core OSH surveillance terminologies, including those for industry and occupation, into the Unified Medical Language System (UMLS). The creation and maintenance of mappings among OSH terminologies and between OSH terminologies and other relevant terminologies already included in the UMLS should be considered.

In the near term:

  • Establish an inventory of relevant OSH terminologies;
  • Develop use cases that benefit from the existence of mappings across OSH terminologies; and
  • Prioritize terminologies in terms of the value that accrues from incorporating them into the UMLS.

In the longer term:

  • Incorporate highest-priority OSH terminologies into the UMLS.

Recommendation L (Chapter 7): NIOSH should lead efforts to establish data standards and software tools for coding and using occupational data in electronic health records. These efforts should be coordinated with the Office of the National Coordinator for Health Information Technology (ONC) to support the establishment of a rule requiring collection and effective use of OSH data in the electronic health record.

In the near term:

  • Develop a consensus within the OSH surveillance community regarding the preferred terminologies and tools for extracting data on industry and occupation from the EHR;
  • Engage with ONC to communicate this consensus to other stakeholders and to establish a broader consensus among all stakeholders regarding an acceptable strategy; and
  • Support ONC in the process of establishing a rule to require the capture of industry and occupation in the EHR.

In the longer term:

  • Work with the occupational medicine and general medicine community to develop models and tools for using occupational data in electronic health records for clinical care and for serving the prevention needs of the clinical population.
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×

Recommendation M (Chapter 7): NIOSH and BLS, working with other relevant agencies, academic centers, and other stakeholders should coordinate and consolidate, where possible, efforts to develop and evaluate state-of-the-art computational and analytical tools for processing free-text data found in OSH surveillance records of all types. This coordination should enable rapid innovation and implementation, into OSH surveillance practice, of successful “autocoding” methods for different data sources.

In the near term:

  • Conduct an inventory of activities and key stakeholders and
  • Support knowledge exchange activities (symposia, competitions).

In the longer term:

  • Develop open data sets that can be used to consistently evaluate methods for extracting OSH data from free text.

Recommendation N (Chapter 7): To identify emerging and serious OSH injuries, illnesses, and exposures in a timely fashion, NIOSH (in coordination with OSHA, BLS, and the states) should develop and implement a plan for routine, coordinated, rapid analysis of case-level OSH data collected by different surveillance systems, followed by the timely sharing of the findings.

In the near term:

  • Develop analytical objectives, identifying the outcomes that would benefit from routine, rapid analysis and continuous monitoring across OSH surveillance systems; and
  • Review technical and legal strategies for conducting analyses, including novel analytical methods and strategies for distributed analysis and ongoing analysis as the data evolve over time.

In the longer term:

  • Implement routine processes for rapid data analysis, including protocols to guide the interpretation of alerts.
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×

Recommendation O (Chapter 7): To promote and facilitate the use of surveillance information for prevention, and to present more comprehensive information on the extent, distribution, and characteristics of OSH injuries, illnesses, and exposures, NIOSH (in coordination with and input from OSHA, BLS, and the states) should establish a coordinated strategy and mechanism for timely dissemination of surveillance information.

In the near term:

  • Clarify target populations for different types of surveillance information (e.g., rapid alerts, trends, etc.);
  • Establish a plan for accessing, integrating, and disseminating information from different surveillance sources; and
  • Develop policies and criteria to address individuals’ and employers’ privacy and confidentiality considerations through a process that provides for stakeholder input and includes privacy experts in the development of these policies and in the design of surveillance systems.

In the longer term:

  • Implement a coordinated information dissemination strategy, making use of different technologies as appropriate to communicate information to those who need it to take action for prevention.

Recommendation P (Chapter 7): NIOSH, OSHA, and BLS should work together to encourage education and training of the surveillance workforce in disciplines necessary for developing and using surveillance systems, including epidemiology, biomedical informatics, and biostatistics.

In the near term:

  • Identify the core competencies required for OSH surveillance and promote the science of surveillance;
  • Review the curricula of existing surveillance courses;
  • Collaborate with educational organizations to establish or modify training programs accordingly; and
  • Require surveillance courses in all funded training programs, especially in the Education and Research Center and Program Project training grants.

In the longer term:

  • Contribute to development of surveillance courses and conferences that provide training in surveillance methods.
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×

Recommendation Q (meta-recommendation, Chapter 8): The Secretary of Health and Human Services, with the support of the Secretary of Labor, should direct NIOSH to form and lead a coordinating entity in partnership with OSHA, BLS, and other relevant agencies. The coordinating entity should:

  • develop and regularly update a national occupational safety and health surveillance strategic plan that is based on well-articulated objectives;
  • coordinate the design and evaluation of an evolving national system of systems for OSH surveillance and for the dissemination of surveillance information provided by these systems;
  • publish a report on progress toward the strategic plan’s implementation at least every 5 years, documenting advances toward achieving a 21st-century smarter occupational safety and health (OSH) surveillance system; and
  • engage partners, including other federal health statistics agencies, state agencies with OSH responsibilities, and stakeholders.
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
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Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
Page 262
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
Page 263
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
Page 264
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
Page 265
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
Page 266
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
Page 267
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
Page 268
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
Page 269
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
Page 270
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
Page 271
Suggested Citation:"Appendix A: Recommendations." National Academies of Sciences, Engineering, and Medicine. 2018. A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/24835.
×
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The workplace is where 156 million working adults in the United States spend many waking hours, and it has a profound influence on health and well-being. Although some occupations and work-related activities are more hazardous than others and face higher rates of injuries, illness, disease, and fatalities, workers in all occupations face some form of work-related safety and health concerns. Understanding those risks to prevent injury, illness, or even fatal incidents is an important function of society.

Occupational safety and health (OSH) surveillance provides the data and analyses needed to understand the relationships between work and injuries and illnesses in order to improve worker safety and health and prevent work-related injuries and illnesses. Information about the circumstances in which workers are injured or made ill on the job and how these patterns change over time is essential to develop effective prevention programs and target future research. The nation needs a robust OSH surveillance system to provide this critical information for informing policy development, guiding educational and regulatory activities, developing safer technologies, and enabling research and prevention strategies that serves and protects all workers.

A Smarter National Surveillance System for Occupational Safety and Health in the 21st Century provides a comprehensive assessment of the state of OSH surveillance. This report is intended to be useful to federal and state agencies that have an interest in occupational safety and health, but may also be of interest broadly to employers, labor unions and other worker advocacy organizations, the workers’ compensation insurance industry, as well as state epidemiologists, academic researchers, and the broader public health community. The recommendations address the strengths and weaknesses of the envisioned system relative to the status quo and both short- and long-term actions and strategies needed to bring about a progressive evolution of the current system.

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