Exhibit G - Fermilab Subcontractor Safety Information Questionnaire.pdf
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- Solicitation number
- RFP-383167-CD
About this file
This document is the Fermilab Subcontractor Injury & Illness Data Questionnaire, a form used to collect occupational safety and health information from prospective or current subcontractors. The questionnaire requires subcontractors to provide company information including name, six-digit NAICS code, address, phone number, and owner identification. Subcontractors must submit three consecutive years of interstate experience modification rates from NCCI Workers Compensation Experience Rating forms, along with complete workers' compensation carrier details including policy number, address, phone, and insurance contact information.
The form requires completion of OSHA 300 log data for the past three years, including total recordable cases, total recordable case rate, cases with days away/restricted/transferred status, the corresponding rate for such cases, employee hours worked, and number of fatalities. Subcontractors must calculate the three-year average for both the recordable case rate and the days away/restricted/transferred case rate using provided formulas, and identify the individual responsible for safety within their organization along with that person's qualifications and years of service. The form requires certification that all provided information is accurate and must be completed by the person responsible for safety within the company. The document was last revised July 2018 and is maintained on the Fermilab ESH&Q Section website.
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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
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 mvidano Typewritten Text Updated through third quarter 2020 mvidano Typewritten Text mvidano Typewritten Text mvidano Typewritten Text mvidano Typewritten Text 231,785 mvidano Typewritten Text 219,795 mvidano Typewritten Text 238,164 mvidano Typewritten Text mvidano Typewritten Text mvidano Typewritten Text mvidano Typewritten Text mvidano Typewritten Text mvidano Typewritten Text mvidano Typewritten Text 2.59 mvidano Typewritten Text 0.91 mvidano Typewritten Text 1.22 mvidano Typewritten Text mvidano Typewritten Text mvidano Typewritten Text
Fermilab ES&H Manual 7010-F1-2 WARNING: This manual is subject to change. The current version is maintained on the ESH&Q Section website. Rev.07/2018
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.
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
EHW
xRCTRCR )000,200()(
= DARTR=
EHW
xDART )000,200()(
Previous
Item 4: Recordable Case Rate Average =
𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌) + 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌) + 𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇(2 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑖𝑖𝑖𝑖𝑢𝑢𝑠𝑠)
Item 5: Lost Work Day Case Rate Average =
𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷(𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌) + 𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷(𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌) + 𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷𝐷(2 𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌𝑌 𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃)
Note 1: NAICS- North American Industry Classification System, formerly known as SIC or Standard Industry Classification Code (Please enter all six digits) mvidano Typewritten Text lbouldin Highlight
Instructions
| Company Name 1: |
| Company Name 2: |
| Phone Number: |
| NAICS 6 digits1 1: |
| NAICS 6 digits1 2: |
| NAICS 6 digits1 3: |
| Current Year: |
| Previous Year: |
| 2 Years Previous: |
| 2 Name of the Workers Compensation Carrier: |
| Policy Number 1: |
| Policy Number 2: |
| Phone Number_2: |
| Name of Contact for Ins Info: |
| 4 Calculate the total recordable case rate averaged over three years: |
| List name and phone number of individual in company responsible for safety: |
| Years of Service: |
| Phone Number_3: |
| Safety TrainingQualificationsCertifications: |
| undefined: |
| 1: |
| 2: |
| Printed Name: |
| Date1_af_date: |
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