Exhibit_F_Form_F3-2.docx

Exhibit F Form F3-2 Environment, Safety and Health Worksheet

Subcontractor Name: Worksheet completed by: Date:

Proposed N3B Subcontract Number: 0000297

1. Experience Modification Rate (EMR)

List your firm’s Interstate EMR for the past three (3) years and total hours worked.

3-year average:

If the state where the jobsite is located has an EMR rating system, provide the state EMR for the past three (3) years and the total hours worked.

3-year average:

2. Total Recordable Case (TRC) and Days Away/Restricted/Transferred Case (DART) Rates

List the cumulative injury statistics rates for the past three (3) years using the BLS formula to determine recordability.

Attach copies of the OSHA Annual Summary Logs (OSHA’s Form 300A) for the three most recent years and a current year OSHA 300 Log for the months during the period since the last annual report.

Any OSHA fine(s) over the past three (3) years? If yes, provide a written explanation on an attachment to this form.

3. Fatalities

Any fatalities within the last three (3) years? If Yes, list total number of fatalities: , and provide a written explanation for each fatality on an attachment to this form.

4. Bureau of Alcohol, Tobacco, and Firearms violations

5. For companies exempt from record keeping requirements per 29 CFR 1904.1 (ten or fewer employees), complete items 1 and 3 above and summarize the cause of the injuries/illnesses for the past three (3) years, including the current year, on a separate attachment to this form. Additionally, include corrective actions taken to prevent re-occurrence.

RFP-0000297

Rev. 1 - February 2017

LA-UR-21898

6. Check your type of work for the most recent 3 year period: Non-Residential Building, include dates:

Heavy (Non-Highway) Construction, include dates: Mechanical, include dates:

Electrical, include dates:

Other (State type and date):

9. Environmental Record

Has your firm been subject to any environmental enforcement proceedings before a federal or state agency within the last five (5) years? If Yes, for each proceeding provide the name of the agency, the nature of the proceeding, the charge(s) and the result on an attachment to this form.

NOTE: THIS FORM IS PRIMARILY FOR BID EVALUATION HOWEVER IS NOT PRECLUDED FROM BECOMING PART OF A RESULTANT SUBCONTRACT.