RFP_Attachment_15_CDRL_A057_Annual_TCIR_DART_Rates.pdf

CONTRACT DATA REQUIREMENTS LIST Form Approved (1 Data/tern) OM8 No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions. searching existing data sources, gathering and maintaining the date needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information. including suggestions for reducing the burden, to the Department of Defense. Executive Services Directorate (0704·01SS), Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMS control number. Plea" do not return your form to the above organization. Send completed form to the Government 'ssuing Contracting Offieer for the Contraet/PR No. It.ted in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

A TOP TM_ OTHER XMGMT

D. SYSTEM liTEM 1\ E. CONTRACT/PR NO. F.CONTRACTOR

C2ISR Division (Non-core IPTs/Wrkctrs) PR FX2399-13-00117 TBD

1, DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

A057 Contractor's Progress, Status and Management Report Annual Total Case Injury Rate (TCIR) and Days Away, Restricted andlor Transferred (DART) Rates

4. AUTHORITY IData Acquisition Document No,) 16, CONTRACT REFERENCE 6, REQUIRING OFFICE

DI-MGMT-80277/T PWS paras 1.3.4.8 and 4.16.6 78 ABW/SE

7. DD 250 REQ : 9. DIST STATEMENT 10. FReQUENCY 12. DATE OF FIRST SUBMISSION 14. DISTRIBUTION

N/A REQUIRED ASREQ SEE BLK 16 b. COPIES

8. APPCODE 11, AS OF DATE 13. DATE OF SUBSEQUENT a. ADDRESSEE Final B SUBMISSION DraftN/A SEEBLK 16 N/A Reg Repro

16. REMARKS 78ABW/SE ]

Block 4: In lieu of paragraph 10 ofDI-MGMT-g0227, the following applies: Submit your 675 7th Street Total Case Injury Rates (TCIR) and Days Away Restricted Time (DARn rates or injury Bldg 707 illness rates for the standard Industrial Classification System (SIC) code or the National Robins AFB GA 31098

American Industrial Classification Systems (NAICS) code for the applicable industry annually using the Bureau ofLabor Statistics (BLS) fonnulas lAW CSP-03-01-003, WR·ALC/GRCKC 1 Voluntary Protection Program (VPP): Policies and Procedures Manual, Appendix A. If 235 Byron Street TCIRIDART rates are not maintained due to OSHA authorized exclusions, submit Suite 19A comparable insurance rates or compensation injury rates. These rates shall be provided to Robins AFB GA 31098 the Installation Safety Office, the Procurement Contracting Officer (PCO), and the CO's

Representative (COR). WR-ALC/GRCBD 1 235 Byron Streel

Block II: TCIRIDART rates are based on calendar year (as ofdate 31 December). Suile 19A

Robins AFB GA 31098 Block 12: Must be provided by 15 January each year.

lnlelink--see Blk 16 1 Block 14: Submission via Government approved electronic fonnat (Intelink), in Microsoft

(MS) Office 2003, or later. Notify Government PCO and COR bye-mail of submission into Intelink. The PCO and COR e-mail addresses will be provided in the contract or in a separate contractual memorandum. Contractor shall request access to Intelink site at www.intelink.gov/. Once Intelink access is granted, contractor shall post data to the following URL address:

https:llwww.intelink.gov/siteslisrdcgsaf/OI;:M1C2ISR%20Divisiono/020SuppoJ1"/020and%

20Services/Fonnsl AllItems.aspx

All electronically delivered files shall be screened for virus and delivered virus free.

15. TOTAL I 0 lj. 0

G. PREPARED BY H.DATE I. APPROVED BY

'.52:' ~ J. ~]).

~ I).

.......,.."..!lfJ........tlNPAKI'Y.. " .."._ 30 May 12 - tltpTJOHNSON.DANNY.J.1061683220 =£~~.~-«W', Al"l'l"t<i'Y A DD FORM 1423-1. FEB 2001 PREVIOUS EDITION MAY BE USED. Page I of_l_ Pages

Adobe ProfeSSional 8,0

17, PRICE GROUP

·"'1-8-.E~S"'T-'M-A"'T--ED"""

TOTAL PRICE