J-6.1 7010_F1_Fermilab Subcontractor Safety Information Questionnaire.docx
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- Attached to
- Argon Piping Supply, Installation and Testing
- Solicitation number
- 73573
About this file
This is a Safety Information Questionnaire template required by Fermilab for subcontractors bidding on federal contract opportunities. The form collects comprehensive occupational safety and health data to evaluate contractor safety performance and risk prior to award.
The questionnaire requires subcontractors to provide: (1) interstate Workers' Compensation Experience Modification Rates for the current year and two prior years, with supporting NCCI rating forms; (2) Workers' Compensation insurance carrier details including policy number, address, and contact information; (3) OSHA 300 log data for three years showing total recordable cases, recordable case rates, days away/restricted/job transferred cases, case rates, employee hours worked, and fatalities; (4) calculated three-year averages for both total recordable case rate and days away/restricted case rate; and (5) identification of the company's safety officer including name, phone number, years of service, and relevant safety training or certifications. The form includes specific formulas for calculating the required safety metrics and requires the safety-responsible individual to certify the accuracy of all information provided. This questionnaire applies to the Argon Piping Supply, Installation and Testing solicitation (Solicitation Number 73573) being issued by the Department of Energy's Fermi National Accelerator Laboratory for pipeline work related to the DUNE experiment.
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Text version
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 |
| 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
DARTR=
Previous
Item 4: Recordable Case Rate Average =
Item 5: Lost Work Day Case Rate Average =
Note 1: NAICS- North American Industry Classification System, formerly known as SIC or Standard Industry Classification Code (Please enter all six digits)
| 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 |
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