Safety Index Rating Form - Virginia Department Of Transportation Page 3
ADVERTISEMENT
1
2
3
4Form C-38
10-3-07
PART 2: Contractor’s Safety Operating Profile (
280 Points)
Listed below are questions to be used to determine your company’s safety operating profile. Please provide the
answers that best describe your company’s present business operating practices regarding safety.
1. List your firm’s Experience Modification Rate (EMR) for the six most recent years:
(Information is
available from your workers’ compensation insurance carrier)
•
If your business does not have six years of rates available use most recent available.
•
If you do not have an EMR, please attach an explanation (i.e. marine contractor).
Year: __________
Rate: __________
Year: __________
Rate: __________
Scoring:
Year: __________
Rate: __________
1 point for each 0.01 the reported average is above
Year: __________
Rate: __________
0.85 not to exceed 50 points
Year: __________
Rate: __________
(i.e. An EMR of 0.91 results in a score of 6 points; an
EMR of 0.79 results in the score of 0)
Year: __________
Rate: __________
Points: ______
Average: __________
2. Using your firm’s OSHA 200/300 log and the formula below, determine your Incidence Rate for
Total Recordable Cases for the three most recent years of available data
†
. The Department will
compare the rate to OSHA’s most recent national industry average for those years.
Incidence Rate for total recordable cases = (Number of recordable incidents -:- total hours worked by all employees during the
calendar year) x 200,000
Contractor
U.S. Industry
††
Year: _____ Rate: _____
Year: _____
Rate: _____
Year: _____ Rate: _____
Year: _____
Rate: _____
Scoring:
Year: _____ Rate: _____
Year: _____
Rate: _____
0 points for Rating ≤ 0.75; 1 point for
Avg.: _____
Avg.: _____
each 0.01 above 0.75 up to a
maximum of 50 points (Rating = 1.25)
(Contractor Avg ÷ Industry Avg)
Rating:
_______
Points: ______
†
Last three available years; Contractor and industry years do not need to reflect the same period.
††
U.S. Industry Rates are available on the Bureau of Labor Standards website:
North American Industry Classification System code (NAICS): __________ (See NAICS codes listed on last page)
Note: If OSHA 200/300 logs are not maintained, please attach an explanation.
3. Has OSHA or VOSH issued to your company and declared final any citation(s) for repeat
violation(s) of any OSHA defined serious injury in Virginia in the past 5 years?
_____Yes _____No. If yes, please attach a detailed list of the violations.
Points: ______
Scoring: 0 Points if answered “No”. If yes, 10 points for each citation not to exceed 60 points.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 8454t - Taxpayer Filing Election Opt Out Form - Virginia Department Of Taxation - Virginia
Financial
Form 25d-6 - Bidder's Registration Form - Alaska Department Of Transportation Civil Rights Office - Dbe Program
Legal
Related Categories
Parent category: Legal