Exhibit I - Fermilab Subcontractor Injury Illness Data Questionnaire.pdf
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- Attached to
- Aspen East 1st floor renovation
- Solicitation number
- ISD-359950-RO
About this file
The document is a Fermilab Subcontractor Injury & Illness Data Questionnaire, a two-page form designed to collect comprehensive safety performance information from potential subcontractors. The questionnaire requires detailed reporting on workers' compensation experience modification rates, workers' compensation insurance details, and three years of OSHA injury and illness data, including total recordable case rates, days away/restricted work cases, employee hours worked, and fatalities. Companies must calculate average recordable case rates and lost work day case rates, and provide information about their safety responsible personnel, with the requirement that the form be completed by the individual most knowledgeable about safety within the organization.
The form is specifically associated with a small business set-aside solicitation (ISD-359950-RO) for the Aspen East 1st floor renovation at Fermi National Accelerator Laboratory, with a NAICS code of 236220 (Commercial and Institutional Building Construction) and a small business size standard of $45.0 million. The renovation project involves extensive interior work including flooring replacement, kitchen demolition, painting, ceiling tile replacement, HVAC and electrical fixture updates, and miscellaneous building improvements. A pre-proposal meeting and site visit was scheduled for May 15th, with specific access requirements for potential bidders, emphasizing citizenship status and security protocols.
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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(𝑇𝑇𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝑌𝑌𝐶𝐶𝑌𝑌𝐶𝐶) + 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝑃𝑃𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃𝑃𝑃𝐶𝐶𝑃𝑃 𝑌𝑌𝐶𝐶𝑌𝑌𝐶𝐶) + 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(2 𝑌𝑌𝐶𝐶𝑌𝑌𝐶𝐶𝑃𝑃 𝑃𝑃𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃𝑃𝑃𝐶𝐶𝑃𝑃)
Item 5: Lost Work Day Case Rate Average =
𝐷𝐷𝐷𝐷𝑇𝑇𝑇𝑇𝑇𝑇(𝑇𝑇𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝑌𝑌𝐶𝐶𝑌𝑌𝐶𝐶) + 𝐷𝐷𝐷𝐷𝑇𝑇𝑇𝑇𝑇𝑇(𝑃𝑃𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃𝑃𝑃𝐶𝐶𝑃𝑃 𝑌𝑌𝐶𝐶𝑌𝑌𝐶𝐶) + 𝐷𝐷𝐷𝐷𝑇𝑇𝑇𝑇𝑇𝑇(2 𝑌𝑌𝐶𝐶𝑌𝑌𝐶𝐶𝑃𝑃 𝑃𝑃𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃𝑃𝑃𝐶𝐶𝑃𝑃)
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 .