INCIDENCE INCIDENCE INCIDENCE RATE FOR RATE FOR RATE FOR LOST INJURIES ILLNESSES DAYS WORK WORKED HOURS) RELATED RELATED OF TO COMPANY WORK WORK HOURS DAYS (A)x(200,000) (B)x(200,000) (C)x(200,000) INJURIES ILLNESSES EMPLOYEES BY OF OF # # LOST (D) (D) (D) (CONVERT TOTAL PROJECT #1: PROJECT #2: COMPANY TOTALS C. Recent OSHA Citation and Disciplinary Action Complete this chart, or attach one with the same format, with your company’s federal and state OSHA citation and disciplinary action, and Experience Modification Ratio (EMR) for the current and past two (2) years. If your EMR is greater than 1.0, you must provide a written explanation. NO. OF NO. OF NO. OF FEDERAL/STATE FEDERAL/STATE NO. OF YEAR EMR FEDERAL/STATE CITATIONS RESOLVED CITATIONS FEDERAL/STATE CITATIONS WITHOUT PENALTY RESOLVED WITH CITATIONS PENDING PENALTY CURRENT: 1 YEAR AGO: 2 YEARS AGO:
# OF WORK RELATED INJURIES # OF WORK RELATED ILLNESSES LOST DAYS OF WORK (CONVERT TO HOURS) TOTAL HOURS WORKED BY COMPANY EMPLOYEES INCIDENCE RATE FOR INJURIES (A)x(200,000) (D) INCIDENCE RATE FOR ILLNESSES (B)x(200,000) (D) INCIDENCE RATE FOR LOST DAYS (C)x(200,000) (D) PROJECT #1: PROJECT #2: COMPANY TOTALS C. Recent OSHA Citation and Disciplinary Action Complete this chart, or attach one with the same format, with your company’s federal and state OSHA citation and disciplinary action, and Experience Modification Ratio (EMR) for the current and past two (2) years. If your EMR is greater than 1.0, you must provide a written explanation. YEAR EMR NO. OF FEDERAL/STATE CITATIONS NO. OF FEDERAL/STATE CITATIONS RESOLVED WITHOUT PENALTY NO. OF FEDERAL/STATE CITATIONS RESOLVED WITH PENALTY NO. OF FEDERAL/STATE CITATIONS PENDING CURRENT: 1 YEAR AGO: 2 YEARS AGO:
FSO-LA-Metro-Elevator-2017-11-JP-Attach-N-Bonding-Requirements-and-Safety-Records.docx