Exhibit M - Fermilab Subcontractor Safety Information Questionnaire.pdf

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)