G - Fermilab Subcontractor Safety Injury and Illness Data Questionnaire.pdf
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- RFP381487CJ
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This is a Fermilab Subcontractor Injury & Illness Data Questionnaire, a template used to collect occupational safety and health information from subcontractors. The form requires subcontractors to provide company identification information including name, NAICS code (six digits), address, phone number, and owner name, along with the submission date.
The questionnaire requests three years of historical safety data across six specific metrics: total number of recordable cases (RC), total recordable case rate (TRCR), total number of cases with days away, restricted work, or job transfer (DART), days away, restricted or job transferred case rate (DARTR), employee hours worked (EHW), and number of fatalities. Subcontractors must also provide workers' compensation experience modification rates for the past three consecutive years with supporting NCCI rating forms, workers' compensation carrier information including policy number and contact details, and copies of OSHA 300A Form log summaries for the three-year period. The form requires calculation of two three-year averages using specified formulas: the recordable case rate average and the lost work day case rate average. Additionally, subcontractors must identify the individual responsible for safety within their company, including name, years of service, phone number, and relevant safety training, qualifications, or certifications. The person completing the form must certify that all information provided is accurate and sign the document.
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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
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 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌 𝑃𝑃
𝑃𝑃𝑃𝑃𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃) 3
Item 5: Lost Work Day Case Rate Average =
𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝑇𝑇𝑇𝑇𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝐶𝐶 𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶) + 𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝑃𝑃𝑃𝑃𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝐶𝐶𝐶𝐶𝑃𝑃 𝑃𝑃 𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶𝑌𝑌𝑌𝑌𝐶𝐶𝐶𝐶) + 𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(2 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌 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)
| Date: |
| Company Name 1: |
| Company Name 2: |
| Phone Number: |
| NAICS 6 digits1 1: |
| NAICS 6 digits1 2: |
| NAICS 6 digits1 3: |
| Current Year: |
| Previous Year: |
| 2 Years Previous: |
| 2 Name of the Workers Compensation Carrier: |
| Policy Number 1: |
| Policy Number 2: |
| Phone Number_2: |
| Name of Contact for Ins Info: |
| Current YearTotal Number of Recordable Cases RC: |
| Previous YearTotal Number of Recordable Cases RC: |
| 2 Years PreviousTotal Number of Recordable Cases RC: |
| Current YearTotal Recordable Case Rate TRCR: |
| Previous YearTotal Recordable Case Rate TRCR: |
| 2 Years PreviousTotal Recordable Case Rate TRCR: |
| Current YearTotal Number of Cases with Days Away Restricted or Job Transferred DART: |
| Previous YearTotal Number of Cases with Days Away Restricted or Job Transferred DART: |
| 2 Years PreviousTotal Number of Cases with Days Away Restricted or Job Transferred DART: |
| Current YearDays Away Restricted or Job Transferred Case Rate DARTR: |
| Previous YearDays Away Restricted or Job Transferred Case Rate DARTR: |
| 2 Years PreviousDays Away Restricted or Job Transferred Case Rate DARTR: |
| Current YearEmployee Hours Worked EHW: |
| Previous YearEmployee Hours Worked EHW: |
| 2 Years PreviousEmployee Hours Worked EHW: |
| Current YearNumber of Fatalities: |
| Previous YearNumber of Fatalities: |
| 2 Years PreviousNumber of Fatalities: |
| 4 Calculate the total recordable case rate averaged over three years: |
| List name and phone number of individual in company responsible for safety: |
| Years of Service: |
| Phone Number_3: |
| Safety TrainingQualificationsCertifications: |
| undefined: |
| 1: |
| 2: |
| Printed Name: |
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