Attachment 10_Fermilab Subcontractor Safety Information Questionnaire.pdf
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- Solicitation number
- 380607-DG
About this file
This is a Fermilab Subcontractor Injury & Illness Data Questionnaire used to evaluate contractor safety performance and compliance with occupational health and safety standards.
The questionnaire requires subcontractors to provide comprehensive injury and illness data covering three consecutive years. Contractors must submit their interstate experience modification rate from the National Council on Compensation Insurance (NCCI) Workers Compensation Experience Rating form, along with workers' compensation carrier information including policy number, carrier name, address, phone number, and insurance contact. Additionally, contractors must complete an OSHA 300 log summary (OSHA 300A Form) documenting recordable cases, total recordable case rates, cases with days away/restricted/job transferred, the corresponding case rates, total employee hours worked, and number of fatalities. Contractors are required to calculate two three-year averages: the total recordable case rate average and the days away/restricted/transferred case rate average using specified formulas. The form also requires identification of the company's safety officer, including name, phone number, years of service, and relevant safety training, qualifications, or certifications. The questionnaire must be completed by and certified as accurate by the person responsible for safety within the contracting company, with signature and printed name required. The document includes detailed calculation formulas and instructions, with a note that the NAICS code (six digits) must be entered for industry classification purposes.
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Text version
Fermilab ES&H Manual 7010-F1-1 WARNING: This manual is subject to change. The current version is maintained on the ESH&Q Section website. Rev.07/2018
Fermilab Subcontractor Injury & Illness Data Questionnaire
Date ____________ Company Name _______________________________________________ NAICS (6 digits)1 _______________________________________________
Address _______________________________________________ Phone Number _______________________________________________ Owner _______________________________________________
1. List interstate experience modification rate for the past three consecutive years.
(Provide a copy of the NCCI Workers Compensation Experience Rating form for each of the years being considered)
Current Year _______ Previous Year _______ 2 Years Previous _______
2. Name of the Workers’ Compensation Carrier __________________________
Policy Number ________________________________________________ Address ________________________________________________ Phone Number ________________________________________________
Name of Contact for Ins. Info _______________________________________
3. Using the OSHA 300 log, fill in the number of injuries and illnesses for the past three years (attach copies of the OSHA 300A Form log summary for the three years being considered).
Description Current Year
Previous Year
2 Years Previous
A Total Number of Recordable Cases (RC)
B Total Recordable Case Rate (TRCR)
C Total Number of Cases with Days Away, Restricted or Job Transferred (DART)
D Days Away, Restricted or Job Transferred Case Rate (DARTR)
E Employee Hours Worked (EHW)
F Number of Fatalities
Fermilab ES&H Manual 7010-F1-2 WARNING: This manual is subject to change. The current version is maintained on the ESH&Q Section website. Rev.07/2018
4. Calculate the total recordable case rate averaged over three years _________
5. Calculate days away, restricted or transferred case rate average over three years _________
6. List name and phone number of individual in company responsible for safety
Name _____________________ Phone Number_________________ Years of Service ____________ Safety Training/Qualifications/Certifications ___________________________
I certify that the information provided on this document is true.
Signature Information supplied by:
Printed Name
Instructions
1) It is strongly recommended that the person completing this form is the person responsible for Safety.
He/she should be familiar with the information requested.
Formulas
EHW
xRCTRCR )000,200()(
= DARTR=
EHW
xDART )000,200()(
Previous
Item 4: Recordable Case Rate Average =
𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌) + 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌) + 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(2 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑖𝑖𝑖𝑖𝑢𝑢𝑠𝑠)
Item 5: Lost Work Day Case Rate Average =
𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷(𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌) + 𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷(𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌) + 𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷(2 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃)
Note 1: NAICS- North American Industry Classification System, formerly known as SIC or Standard Industry Classification Code (Please enter all six digits)
Instructions
File details come from the government source that posted it. Updated .