FRA Safety Questionnaire (Rev. 08-17)_URV.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 ________________________________________________ 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