Attachment_D_Past_Performance_Worksheet_for_Safety_-_Amendment_0001.docx

ATTACHMENT D

PAST PERFORMANCE WORKSHEET FOR SAFETY

OFFEROR:

FACTOR 4: Offerors are required to provide the following information for safety and health programs:

a. Experience Modification Rate (EMR) for the current and five (5) previous complete calendar years.

b. OSHA Days away from work, restricted duty or job transfer (DART) rate for the current and five (5) previous complete calendar years.

c. Technical approach for safety

Use the following table to provide information for the above criteria. Use attached sheets (limited to two pages) to supply Technical Approach for Safety.

SAFETY AND HEALTH PROGRAM

ACCIDENT AND INJURY STATISTICS

Experience Modification Rate

OSHA DART Rate

Technical approach

1. Experience Modification Rate (EMR):

For the current and five previous complete calendar years [2013, 2012, 2011, 2010, 2009, 2008], submit your EMR (which compares your company’s annual losses in insurance claims against its policy premiums over a five year period). If you have no EMR, affirmatively state so, and explain why. Any extenuating circumstances, including corrective actions taken, that affected the EMR and upward or downward trends should be addressed as part of this element. Lower EMRs will be given greater weight in the evaluation.

2. Occupational Safety and Heal Administration (OSHA) Days Away from Work, Restricted Duty, or Job Transfer (DART) Rate and OSHA Forms 300 and 300A:

For the current and five previous complete calendar years [2013, 2012, 2011, 2010, 2009, 2008], submit your OSHA DART rate. The OSHA DART rate shall be calculated as defined by the U.S. Department of Labor, OSHA. If you cannot submit an OSHA DART Rate, affirmatively state so, and explain why. Any extenuating circumstances, including corrective actions taken, that affected the OSHA DART Rate data and upward or downward trends should be addressed as part of this element. Lower OSHA DART Rates will be given greater weight in the evaluation.

For the current and previous complete calendar years [2013, 2012, 2011, 2010, 2009, 2008] submit OSHA Forms 300 and 300A. If you cannot submit OSHA Forms 300 and 300A affirmatively state so, and explain why.

3. Technical Approach for Safety:

Describe the plan and criteria that the Offeror will implement to evaluate safety performance of potential subcontractors, as a part of the selection process for all levels of subcontractors. Also, describe any innovative methods that the Offeror will employ to ensure and monitor safe work practices at all subcontractor levels. The Safety Narrative shall be limited to two pages.

Revised 7 December 2011 1

SOURCE SELECTION SENSITIVE INFORMATION

DISCLOSURE LIMITATIONS AS OUTLINED IN FAR 2.101 & 3.104 APPLY