3-09 - COM JOC Section J Exhibit D Safety Data.docx

EXHIBIT “D”

SAFETY DATA SHEET

This form is to be completed by the Offeror. Use this form to provide safety information for the Safety factor. EMR, DART and TRC rates shall not be submitted for subcontractors.

Joint Venture (JV) or Partnership: Complete Blocks 1 through 8 for each contractor who is part of the JV or partnership. Only one safety narrative (Block 9) is required.

1. Offeror Name:

Name of JV partner providing the information below (if applicable):

Offeror’s Three Previous Complete Calendar Years of Reported Safety Data:

Only complete year safety data will be considered. Indicate data rates as decimal figures, not whole numbers.

3a. For EMRs greater than 1.0, explain any extenuating circumstances and corrective actions taken:

3b. Explain any negative EMR trends:

3c. If you do not have an EMR for a given year, state so here and explain why:

NOTE: “N/A” or “Not Applicable” is not an acceptable response. If you state your rate is Zero OR your firm does not qualify for an EMR rate, provide supporting documentation from insurance carrier.

4. Insurance Carrier Information:

Insurance Carrier Name:

Instructions for calculating the DART rate can be found at http://www.bls.gov/iif/osheval.htm.

6a. For DART Rates of 3.0 or greater, explain any extenuating circumstances and corrective actions taken:

6b. Explain any negative DART Rate trends:

6c. If you do not have a DART Rate for a given year, state so here and explain why:

NOTE: “N/A” or “Not Applicable” is not an acceptable response. If you state your rate is Zero, provide supporting labor hours and mishap log.

Note: Form may be expanded.

EXHIBIT “D” (continuation)

SAFETY NARRATIVE

Instructions for calculating the TRC rate can be found at http://www.bls.gov/iif/osheval.htm.

8a. For TRC Rates of 4.5 or greater, explain any extenuating circumstances and corrective actions taken:

8b. Explain any negative TRC Rate trends:

8c. If you do not have a TRC Rate for a given year, state so here and explain why:

NOTE: “N/A” or “Not Applicable” is not an acceptable response. If your state your rate is Zero, provide supporting labor hours and mishap log.

EXHIBIT “D” (continuation)

SAFETY NARRATIVE

9. Technical Approach for Safety: Provide the Safety Narrative using this form. Do not exceed page limitation specified in the RFP. Any additional pages will not be considered.

Describe the plan that the Offeror will implement to evaluate safety performance of potential subcontractors, as a part of the selection process for all levels of subcontractors:

Describe the safety management system that the Offeror will use to oversee the safety compliance and performance of self-performed and subcontractor performed work:

Note: Form may be expanded up to the page limit specified in the RFP.

EXHIBIT “D” (continuation)

SAFETY NARRATIVE

9. Technical Approach for Safety (continuation): Provide the Safety Narrative using this form. Do not exceed page limitation specified in the RFP. Any additional pages will not be considered.

Describe any innovative methods that the Offeror will employ to ensure and monitor safe work practices at self-performed/and or all subcontractor levels:

Describe the methodology that the Offeror will use in order to execute an effective program that facilitates sound mishap prevention techniques and processes, employee reporting of unsafe conditions, unsafe activities, and near-miss mishaps, including a description of your “Good Catch” program: