Exhibit J - Fermilab Subcontractor Safety Information Questionnaire

Fermilab Subcontractor Injury & Illness Data Questionnaire 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)

Address
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).
Updated through third quarter 2020

Current
Year

Previous
Year

2 Years

Previous

1.22

0.91

2.59

238,164

219,795

231,785

Description
A

Total Number of Recordable Cases (RC)

B

E

Total Recordable Case Rate (TRCR)
Total Number of Cases with Days Away,
Restricted or Job Transferred (DART)
Days Away, Restricted or Job Transferred
Case Rate (DARTR)
Employee Hours Worked (EHW)

F

Number of Fatalities

C
D

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

over three years
6. List name and phone number of individual in company responsible for safety 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

TRCR =

( RC ) x(200,000)
EHW

DARTR=

( DART ) x(200,000)

EHW

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)

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