Exhibit J_Fermilab Subcontractor Safety Information Questionnaire.pdf
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- Solicitation number
- 378957-DG
About this file
This document is a Fermilab Subcontractor Injury & Illness Data Questionnaire template used to collect occupational safety and health information from prospective subcontractors.
The questionnaire requires subcontractors to provide company identification information (name, NAICS code, address, phone number, and owner name) and complete six primary data sections. Section 1 requests interstate experience modification rates for the past three years with supporting NCCI Workers Compensation Experience Rating forms. Section 2 requires workers' compensation carrier details including policy number, address, phone number, and insurance contact information. Section 3 mandates completion of injury and illness data from OSHA 300 logs for the preceding three years, including total recordable cases (RC), total recordable case rates (TRCR), cases with days away/restricted/job transferred (DART), DART rates (DARTR), employee hours worked (EHW), and fatalities, with attached OSHA 300A Form summaries. Sections 4 and 5 require calculation of three-year averages for recordable case rates and days away/restricted/transferred case rates using provided formulas. Section 6 requests identification of the company's safety officer with name, phone number, years of service, and safety training/qualifications/certifications. The form must be signed by an authorized company representative certifying the accuracy of provided information. The document includes detailed formulas and instructions, with emphasis that the person completing the form should be the individual responsible for safety within the organization.
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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 ________________________________________________ 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 .