3410 Appendix T3

Subcontractor ES&H Evaluation

 

 

Construction Subcontractor Technically Acceptable Safety and Health (S&H) Program Worksheet

Contract Number & Title: 

Date: 

 Subcontractor: 

Safety and Health (S&H) Program (total possible points)

Workers Compensation Experience Modification Rating (total possible score – 50 points)

 

3-Yr Avg.

0.69

0.70 – 0.80

0.81 – 0.90

0.91 – 1.00

1.01 – 1.10

1.11 – 1.25

1.26 – 1.50

1.51 – 1.75

≥ 1.76

Points

50

45

40

35

30

25

20

10

0

 

Contractor’s 3-Year EMR: _____________

                                                      Points:__________

 

Injury Rates (total possible score – 10 points)

 

Subcontractor’s NAISC Code: ________________

 

Department of Labor’s Current Average Injury Rates

 

Total Recordable Case (TRC) Rate: ____________

 

Days Away, Restricted, or Transferred (DART) Case Rate: ___________

Subcontractor’s 3-Year Average Injury Rates

 

TRC Rate: __________________                                                                                       

 ≤ 25% of the current Industry Average Rate, add 10 pts; >25% = 0 pts).                           Points: __________

 

DART Case Rate: ____________                                                                                       

≥ 50% of the current Industry Average Rate, deduct 10 pts;<50%= 0 pts.)                        Points: _________

 

OSHA/VOSH Violations

 

If no data is available from www.osha.gov, assign 0 pts in both categories. Deduct 10 pts for each serious violation in past 3 yrs. If no serious violations, assign 0 pts.                                              

           Points: __________

 

Safety Program Elements (total possible score – 24 points)

·      Evidence of viable hazard-analysis process in work planning (worksheet, instructions, etc.).

·      Evidence of new employee orientation with safety emphasis (course outline or syllabus, name and qualifications of instructor).

·      Accident investigation process, including lessons learned component.

·      Safety performance as part of project manager and/or superintendent’s evaluation.

·      Job-site safety inspections by qualified person not part of project (corporate safety, insurance company, etc.).

·      Toolbox/job planning meetings prior to work being performed.                                  Points: __________

 

Past Jefferson Lab Experience (total possible score – 20 points)

Superintendent and/or Safety Representative has experience working at Jefferson Lab and the subcontractor has a positive safety record that spans the past 3 yrs. (Subcontractor did not receive fines for ES&H violations, contractor DART and TRC were below industry average for the past project, or subcontractor developed and applied lessons learned on the past project.)       

                                                                                                                                              Points: __________

 

                                                                                                    TOTAL POINTS: _________________________

Subcontractor must have total of 55 points to be considered acceptable from an ES&H standpoint.

 

Is subcontractor acceptable?             oYES            oNO

 

EVALUATED BY: _________________________________________________________

ES&H Division

                                                          

                                                                                              

Form Revision Summary

 

Revision 0.1 – 03/23/19 – Periodic Review; updated TPOC from B.May to B.Rainey

Revision 0.0 – 03/23/16 – New Content

 

ISSUING AUTHORITY

FORM TECHNICAL POINT-OF-CONTACT

APPROVAL DATE

REVIEW DATE

REV.

 

 

ES&H Division

Bill Rainey

03/23/19

03/23/22

0.1

 

This document is controlled as an on line file.  It may be printed but the print copy is not a controlled document.  It is the user’s responsibility to ensure that the document is the same revision as the current on line file.  This copy was printed on 3/21/2019.