Attachment I - Safety Factor.pdf

Attachment “I” – Safety Factor Form, Page 1 of 3

ATTACHMENT “I”

SAFETY DATA SHEET

This form is to be completed by the Offeror. Use this form to provide safety information for the Safety factor. EMR, DART, and TRC rates shall not be submitted for subcontractors.

Joint Venture (JV) or Partnership: Complete Blocks 1 through 7 for each contractor who is part of the JV or partnership.

Only one safety narrative (Block 8) is required.

1. Offeror Name:

Name of JV partner providing the information below (if applicable):

Offeror’s Three Previous Complete Calendar Years of Reported Safety Data:

Only complete year safety data will be considered. Indicate data rates as decimal figures, not whole numbers.

2. Experience Modification Rate (EMR): 2016 2017 2018

3a. For EMRs greater than 1.0, explain any extenuating circumstances and corrective actions taken:

3b. Explain any upward or downward EMR trends:

3c. If you do not have an EMR for a given year, state so here and explain why:

4. Insurance Carrier Information:

Insurance Carrier Name:

Agent’s name: Phone No.: Email:

5. U.S. Dept. of Labor, OSHA Days Away from Work, Restricted Duty, or Job Transfer (DART) Rate

2016 2017 2018

Instructions for calculating the DART rate can be found at http://www.bls.gov/iif/osheval.htm.

6a. For DART Rates of 3.0 or greater, explain any extenuating circumstances and corrective actions taken:

6b. Explain any upward or downward DART Rate trends:

6c. If you do not have a DART Rate for a given year, state so here and explain why:

http://www.bls.gov/iif/osheval.htm

ATTACHMENT “I” (continuation)

SAFETY NARRATIVE

7. U.S. Dept. of Labor, OSHA Total Recordable Case (TRC)

Rate 2016 2017 2018

Instructions for calculating the TRC rate can be found at http://www.bls.gov/iif/osheval.htm.

8a. For TRC Rates of 4.5 or greater, explain any extenuating circumstances and corrective actions taken:

8b. Explain any upward or downward TRC Rate trends:

8c. If you do not have a TRC Rate for a given year, state so here and explain why:

8. Technical Approach for Safety: Provide the Safety Narrative using this form. Do not exceed page limitation specified in the RFP. Any additional pages will not be considered.

Describe the plan that the Offeror will implement to evaluate safety performance of potential subcontractors, as a part of the selection process for all levels of subcontractors:

Describe the safety management system that the Offeror will use to oversee the safety compliance and performance of self-performed and subcontractor performed work:

http://www.bls.gov/iif/osheval.htm

ATTACHMENT “I” (continuation)

SAFETY NARRATIVE

8. Technical Approach for Safety (continuation): Provide the Safety Narrative using this form. Do not exceed page limitation specified in the RFP. Any additional pages will not be considered.

Describe any innovative methods that the Offeror will employ to ensure and monitor safe work practices at self-performed and all subcontractor levels:

Describe the methodology that the Offeror will use in order to execute an effective program that facilitates sound mishap prevention techniques and processes, employee reporting of unsafe conditions, unsafe activities, and near-miss mishaps:

Note: Form may be expanded up to the page limit specified in the RFP.