Att 4 - ESH Risk Evaluation Form.pdf

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National Renewable Energy Laboratory

ENVIRONMENT, SAFETY, AND HEALTH

OFFEROR OR LOWER-TIER SUBCONTRACTOR RISK EVALUATION WORKSHEET

OFFEROR OR LOWER-TIER SUBCONTRACTOR INFORMATION

Offeror (or Lower-Tier Subcontractor) Date of Submission Policy Period North American Industry Classification System Code

RISK EVALUATION

Initial Review and Acceptance. Offerors and their lower-tier subcontractors are required to meet NREL-acceptable environment, safety, and health (ESH) qualification criteria prior to being awarded a subcontract or lower-tier subcontract to perform work at an NREL site. NREL considers a three-year average experience modification rate (EMR) of less than or equal to 1.00 AND a “No” response to questions 2, 3, and 4 to be acceptable.

Additional Evaluation and Assessment. Offerors or lower-tier subcontractors that report a three-year average EMR above 1.00 OR have responded “Yes” to questions 2, 3, and/or 4 are required to provide responses to questions 5 and 6 below. The ESH point of contact will evaluate and assess the offeror’s or lower-tier subcontractor’s additional responses to determine offeror or lower-tier subcontractor acceptability. However, NREL reserves the right to consider additional information requested by NREL used to determine whether the offeror or lower-tier subcontractor is accepted or rejected.

1. Submit Your Experience Modification Rate (EMR). Request a letter from your insurance company indicating your EMR for the current policy period and past 3 policy periods (four policy periods in total). The letter must be on the insurance company’s letterhead and loss runs will not be accepted in lieu of letter. An example letter is attached for reference. Completed?

Yes No If no, provide a written explanation for not providing EMR history

2. Occupational Safety and Health Administration (OSHA) Citations. Has your firm received one or more OSHA citations in the last three years?

Yes No If yes, provide a written explanation for each incident in an attachment to this form.

3. Fatalities, Multiple Hospitalizations, or Amputation(s). Has your firm experienced a single work-related incident resulting in a fatality, inpatient hospitalization, loss of an eye, or amputation(s) in the last three years?

Yes No If yes, provide a written explanation for each citation in an attachment to this form.

4. Environmental Record. Has your firm received violations pertaining to federal, state, or local environmental standard, regulation, or statute in the last three years?

Yes No If yes, provide a written explanation for each violation in an attachment to this form.

If the offeror or lower-tier subcontractor reports a three-year average EMR of less than or equal to 1.00 AND has provided a “No” response to questions 2, 3, and 4, responses to questions 5 and 6 are not required.

If the offeror or lower-tier subcontractor reports a three-year average EMR above 1.00 OR has responded “Yes” to questions 2, 3, and/or 4, responses to questions 5 and 6 are required.

5. Occupational Total Recordable Case (TRC) Rate Statistics. List your firm’s occupational injury statistics for the past three full calendar years using the Bureau of Labor Statistics formula to determine the TRC rate. The offeror must attach copies of the OSHA logs (OSHA 300 log and 300A) for the previous three years, and a current OSHA 300 log for the months during the period since the last annual report.

NOTE. TRC rate is the number of OSHA recordable injuries and illnesses per 100 full-time equivalent (FTE) workers. The common exposure base enables one to make accurate inter-industry comparisons, trend analysis over time, or compare among firms regardless of size. The rate is calculated as: N*200,000/EH (where N = number of OSHA recordable injuries/illnesses;

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200,000 = base for 100 FTEs [working 40 hours per week, 50 weeks per year]; and EH = total hours worked by employees during the calendar year).

OSHA TRC Rate:

Year # of OSHA TRC cases Man-hours Rate Year # of OSHA TRC cases Man-hours Rate Year # of OSHA TRC cases Man-hours Rate

Three-year average

6. Occupational Days Away/Restricted or Transfer (DART) Rate Statistics. List your firm’s DART rate for the past three full calendar years using the Bureau of Labor Statistics formula to determine the rate.

NOTE. The DART rate is a mathematical calculation that characterizes the number of OSHA recordable injuries and illnesses per 100 FTEs that resulted in days away from work, restricted work activity, and/or job transfers that a company has experienced in a given timeframe. The rate is calculated as: N*200,000/EH (where N = number of OSHA injury/illness cases resulting in days away/restricted or job transfer (OSHA’s Form 300, Columns H + I); 200,000 = base for 100 FTEs [working 40 hours per week, 50 weeks per year]; and EH = total hours worked by employees during the calendar year).

OSHA DART Rate:

Year # of OSHA DART cases Man-hours Rate Year # of OSHA DART cases Man-hours Rate Year # of OSHA DART cases Man-hours Rate Three-year average

FOR NREL USE ONLY – OFFEROR OR LOWER-TIER SUBCONTRACTOR ACCEPTABILITY EVALUATION – DO NOT WRITE

BELOW THIS LINE

Offeror or lower-tier subcontractor accepted EMR ≤ 1.0 AND response to questions 2, 3, and 4 is “No”; or Other (provide explanation in comments)

Offeror or lower-tier subcontractor rejected

EMR > 1.0

Offeror or lower-tier subcontractor responded “Yes” to question 2, 3, and/or 4 (provide explanation in comments) OSHA TRC (provide explanation in comments) OSHA DART (provide explanation in comments) NREL past performance letters (provide explanation in comments and attach Acquisition Services letter) NREL past incident history (provide explanation in comments) Other (provide explanation in comments)

Comments

CERTIFICATION

A person authorized to make legally binding commitments on behalf of the offeror or lower-tier subcontractor must sign below. By signing below, the offeror or lower-tier subcontractor certifies, under penalty of law, that the responses provided in this worksheet are accurate.

Company/Organization Name

Signature Signer’s Printed Name

Title Date

Telephone Number Email address

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