Safety_Data_Sheet.docx

SAFETY DATA SHEET

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

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

1. Offeror Name:

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

2. Insurance Carrier Information:

Insurance Carrier Name:

Agent’s name:

Phone No.:

Email:

Offeror’s Five 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.

3. OSHA Days Away from Work, Restricted Duty, or Job Transfer (DART) Rate

3a. If you do not have a DART Rate for a given year, affirmatively state so here and explain why:

3b. Explain any negative trend above moderate risk (DART Rates of 3.0 or greater), an acceptable/detailed explanation is required that includes any corrective actions taken for improvement:

4. Total Recordable Case (TCR) Rate

4a. If you do not have a TCR Rate for a given year, affirmatively state so here and explain why:

4b. Explain any negative trend above moderate risk (TCR Rates of 4.5 or greater), an acceptable/detailed explanation is required that includes any corrective actions taken for improvement:

SAFETY DATA SHEET (Continuation)

5. Technical Approach for Safety: Provide the Safety Narrative using this form. Do not exceed 2 pages. Any additional pages will not be considered.

a. Describe the Offeror’ s approach to implementing and executing a Safety Management System (SMS) including Management/Leadership involvement, Employee involvement, Hazard prevention, Hazard control, Worksite analysis, and Safety and health training, to include the standard(s) used to benchmark the SMS.

b. Describe the evaluation process used to select potential subcontractors.

c. Describe the processes of how the Offeror will oversee safety compliance of subcontractors at all levels throughout performance of the contract (to include the Offeror’s own in-house workforce).