Exhibit H Fermilab Subcontractor Safety Information Questionnaire.pdf
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About this file
This document is a Fermilab Subcontractor Injury & Illness Data Questionnaire. It requires the subcontractor to provide information on their past three years of interstate experience modification rates, workers' compensation insurance details, and injury/illness data from their OSHA 300 logs. The subcontractor must calculate their total recordable case rate and days away, restricted or transferred case rate averages over the three-year period. They must also provide the name and contact information of the individual responsible for safety. This information is required as part of the federal contract opportunity for Fermilab Backflow Preventer Maintenance Services. The solicitation involves providing all personnel, supplies, supervision, tools, materials, equipment, and transportation necessary to maintain approximately 121 backflow devices at the Fermi National Accelerator Laboratory. The contract will be for a 2-year base period with three 1-year option periods.
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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
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
Instructions
Formulas
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 Years of Service
Safety Training/Qualifications/Certifications
I certify that the information provided on this document is true.
Signature Information supplied by:
Printed Name
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.
(RC)x(200,000)
TRCR DARTR=
EHW
(DART )x(200,000)
EHW
Item 4: Recordable Case Rate Average =
𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝑇𝑇𝑇𝑇𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝐶𝐶 𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶) + 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝑃𝑃𝑃𝑃𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝐶𝐶𝐶𝐶𝑃𝑃 𝑃𝑃 𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶) + 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(2 𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶𝑃𝑃 𝑃𝑃
𝑃𝑃𝑃𝑃𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃) 3
Item 5: Lost Work Day Case Rate Average =
𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝑇𝑇𝑇𝑇𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝐶𝐶 𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶) + 𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝑃𝑃𝑃𝑃𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝐶𝐶𝐶𝐶𝑃𝑃 𝑃𝑃 𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶) + 𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(2 𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶𝑃𝑃 𝑃𝑃 𝑃𝑃𝑃𝑃𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃)
Previous
Note 1: NAICS- North American Industry Classification System, formerly known as SIC or Standard Industry Classification Code (Please enter all six digits)
| Date: |
| Company Name 1: |
| Company Name 2: |
| Phone Number: |
| NAICS 6 digits1 1: |
| NAICS 6 digits1 2: |
| NAICS 6 digits1 3: |
| Current Year: |
| Previous Year: |
| 2 Years Previous: |
| 2 Name of the Workers Compensation Carrier: |
| Policy Number 1: |
| Policy Number 2: |
| Phone Number_2: |
| Name of Contact for Ins Info: |
| Current YearTotal Number of Recordable Cases RC: |
| Previous YearTotal Number of Recordable Cases RC: |
| 2 Years PreviousTotal Number of Recordable Cases RC: |
| Current YearTotal Recordable Case Rate TRCR: |
| Previous YearTotal Recordable Case Rate TRCR: |
| 2 Years PreviousTotal Recordable Case Rate TRCR: |
| Current YearTotal Number of Cases with Days Away Restricted or Job Transferred DART: |
| Previous YearTotal Number of Cases with Days Away Restricted or Job Transferred DART: |
| 2 Years PreviousTotal Number of Cases with Days Away Restricted or Job Transferred DART: |
| Current YearDays Away Restricted or Job Transferred Case Rate DARTR: |
| Previous YearDays Away Restricted or Job Transferred Case Rate DARTR: |
| 2 Years PreviousDays Away Restricted or Job Transferred Case Rate DARTR: |
| Current YearEmployee Hours Worked EHW: |
| Previous YearEmployee Hours Worked EHW: |
| 2 Years PreviousEmployee Hours Worked EHW: |
| Current YearNumber of Fatalities: |
| Previous YearNumber of Fatalities: |
| 2 Years PreviousNumber of Fatalities: |
| 4 Calculate the total recordable case rate averaged over three years: |
| List name and phone number of individual in company responsible for safety: |
| Years of Service: |
| Phone Number_3: |
| Safety TrainingQualificationsCertifications: |
| undefined: |
| 1: |
| 2: |
| Printed Name: |
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