Attachment 9 Safety and Health Program.pdf
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- Solicitation number
- 80KSC025R0008
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This document is an Attachment 9 Safety and Health Program form for a federal contract (Solicitation Number 80KSC020R0028) requiring contractors to provide detailed safety performance documentation. The form mandates submission of independently documented evidence including OSHA Total Recordable Incidence Rate (TRIR), DART rate, Experience Modifier Rate (EMR), and comprehensive safety incident information for the past three years. Contractors must provide their safety metrics for each category, which will be compared against industry averages, and include supporting documentation such as OSHA logs, insurance carrier letters, and detailed accounts of any safety citations, violations, reportable mishaps, or fatalities that have occurred during the specified time period.
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80KSC020R0028 - ATTACHMENT 9
SAFETY AND HEALTH PROGRAM
CONTRACTOR NAME:
1. Independently documented evidence (OSHA 300 & 300A log is evidence) of your firm’s designated OSHA Total Recordable Incidence Rate (TRIR) with NAICS code. You must provide your current Recordable Incidence Rate (RIR) and the previous three year’s (TRIRs). The following web site is available to help you compute this rate: http://www.bls.gov/iif/osheval.htm.
These rates will be compared to the most recent industry averages of like NAICS codes found on the same web page.
Last Full Calendar Year:____________ Previous Year:__________________ 2 Years Previous:__________________ 3 Year Average:_________________ NAICS CODE:___________________ Number of Employees___
2. Independently documented evidence (OSHA 300 & 300A log is evidence) of your firm’s OSHA DART rate (Days away from work, days of restricted work activity or job transfer) with NAICS code.
You must provide your current DART rate and the previous three year’s DART rates. The following web site is available to help you compute this rate: http://www.bls.gov/iif/osheval.htm.
These rates will be compared to the most recent industry averages of like NAICS codes found on the same web page.
Last Full Calendar Year:____________ Previous Year:__________________ 2 Years Previous:__________________ 3 Year Average:_________________ NAICS CODE:___________________ Number of Employees___
3. Independently documented evidence (letter from your insurance carrier) of your firm’s designated Safety Experience Modifier Rate (EMR) used to calculate Workmen’s Compensation Insurance. You must provide your current EMR rating and the previous three year’s EMR ratings. This rate will be compared to the industry average rate of 1.0.
Last Full Calendar Year:____________ Previous Year:__________________ 2 Years Previous:__________________ 3 Year Average:_________________
4. Information on all OSHA citations or Safety Violation issued to the firm over the past three years.
5. Information on all previous OSHA reportable mishaps (OSHA Forms 300 & 300A) or Mishaps from Government Entities that have occurred in the past three years. Address any fatalities that have occurred; identify whether the investigation has been completed and the results; The cause of the safety and health mishap; Describe the corrective action taken and when it was implemented. If the corrective action has not yet been implemented, provide the planned implementation date.
6. Include a letter from your insurance carrier regarding your EMR rate.
| CONTRACTOR NAME: |
| Last Full Calendar Year: |
| Previous Year: |
| 3 Year Average: |
| 2 Years Previous 1: |
| 2 Years Previous 2: |
| NAICS CODE: |
| Number of Employees: |
| Last Full Calendar Year_2: |
| Previous Year_2: |
| 3 Year Average_2: |
| 2 Years Previous 1_2: |
| 2 Years Previous 2_2: |
| NAICS CODE_2: |
| Number of Employees_2: |
| Last Full Calendar Year_3: |
| Previous Year_3: |
| Years Previous: |
| 3 Year Average_3: |
| 4 Information on all OSHA citations or Safety Violation issued to the firm over the past three years: |
| 1: |
| 2: |
| action has not yet been implemented provide the planned implementation date 1: |
| action has not yet been implemented provide the planned implementation date 2: |
| 6 Include a letter from your insurance carrier regarding your EMR rate: |
File details come from the government source that posted it. Updated .