Attachment 5 - SAFETY DATA SHEET.docx

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: Provide a Safety Data Sheet for each contractor who is part of the JV or partnership; however, only one safety narrative 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.

2a. Explain any extenuating circumstances resulting in any EMRs greater than 1.0:

2b. Explain any upward or downward EMR trends:

2c. If you do not have an EMR for a given year, state so here and explain why:

3a. Explain any extenuating circumstances resulting in any DART Rates of 3.0 or greater:

3b. Explain any upward or downward DART Rate trends:

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

4a. Explain any extenuating circumstances resulting in any TRC Rates of 4.5 or greater:

4b. Explain any upward or downward TRC Rate trends:

4c. If you do not have a DART Rate for a given year, state so here and explain why:

SAFETY NARRATIVE

5. Technical Approach for Safety: Provide the Safety Narrative using this form. Do not exceed 2 pages. 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 any innovative methods that the offeror will employ to ensure and monitor safe work practices at all subcontractor levels:

Describe proposed methodology to execute an effective program that facilitates sound mishap prevention techniques and processes, employee reporting of unsafe conditions, unsafe activities, and near-miss mishaps.