J-L-05.docx

J-L-05

SAFETY DATA & NARRATIVE

SOLICITATION NO: N62473-16-R-1017

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

Joint Venture (JV): Provide a safety Data Sheet for each contractor who is part of the JV; however, only one safety narrative is required.

1. Offeror Name:

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

Offeror’s Three Previous (complete) Years of Reported Safety Data:

Only complete year safety data will be considered. Indicate data rates as decimal figures, not whole numbers. NOTE: Blank entries will be considered non-responsive. If you have no established rates, annotate block with “see narrative below.”

3a. Explanation of any extenuating circumstances resulting in any EMRs greater than 1.0 and address any corrective action(s) taken:

3b. Explain any upward 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 Number:

*For each year, submit a completed copy of U.S. Dept. of Labor, OSHA Form 300A (Summary of Work-Related Injuries and Illnesses), latest version. This information is required regardless of number of employees in the company.

6a. Explain any extenuating circumstances resulting in any DART rates 3.0 or greater and address any corrective action(s) taken:

6b. Explain any upward DART rate trends:

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

J-L-05

SAFETY DATA & NARRATIVE

SOLICITATION NO: N62473-16-R-1017

7. Provide the Technical Approach for Safety using this form. The Technical Approach for Safety Narrative shall not exceed two (2) single-sided pages (or one (1) double-sided page). Any additional pages will not be considered.

Technical Approach for Safety:

7a. Describe the plan the offeror will implement to evaluate the safety program and performance of potential subcontractors:

7b. Describe the plan to monitor subcontractor worksite safety:

7c. Describe any innovative methods the offeror will employ that may enhance worksite safety for this procurement:

Note: Form may be expanded.