Safety Qualification Form INSTRUCTIONS Complete all yellow cells with accurate responses. "Information provided shall apply to any and all construction work the Firm has completed as Prime, Joint Venture Partner or Subcontractor." 1. Contact Information Company Name: Company Address: Street "City, State, Zip Code" Telephone Number Company Representative Name Company Representative Email Company Representative Phone Number 2. Acknowledgement Please print and sign a hard copy of your Safety Qualification Form. "By signing this Safety Qualification Form, the undersigned certifies under penalty of perjury that signer personally reviewed all information contained in this submittal and certifies that all information provided is complete, accurate, and contains no false or misleading information. " Signature Name: Title Date: 3. Documents to Submit with this Form 3.a. Submit the past three years of your firm's OSHA 300A forms. "3.b. If required to complete Step 3 (below), submit the following documents:" 3.b.1. Additional documents specified in Step 3. "3.b.2. Explanation of any OSHA violations identified in Step 3, below" "3.b.3. Explanation of any fatalities identified in Step 3, below" PRT may in its sole discretion adjust your firm's Safety Qualification status based on information in the above-referenced documents submitted with this form. Step 1 4. Occupational Safety and Health Administration (OSHA) For 300A Summary of Work-Related Injuries and Illness "4a. Please provide your firm's data from your OSHA 300A forms. The data should be for all construction work your firm performed wether as a prime, as part of a joint venture or as a subcontractor." Year 2017 2018 2019 Total number of deaths (G) Total Number of Cases with days away from work (H) Total Number of cases with job transfer or restriction (I) Total number of other recordable cases (J) Average number of Employees Total hours worked by all employees 2017 Total recordable case rate (Automatically Calculated): 2018 Total recordable case rate (Automatically Calculated): 2019 Total recordable case rate (Automatically Calculated): "2017 Total cases with days away from work, job restriction, or transfer rate (Automatically Calculated):" "2018 Total cases with days away from work, job restriction, or transfer rate (Automatically Calculated):" "2019 Total cases with days away from work, job restriction, or transfer rate (Automatically Calculated):" 4b. Enter the North America Industrial Classification System (NAICS) rate associated with your industry from this source: Provide the NAICS Industry Code from your 2018 300A form: Please provide the following information from this source: https://www.bls.gov/iif/oshwc/osh/os/summ1_00_2018.htm "Please type in the ""Industry"" category name for your firm's NAICS code:" "Please provide your industry's ""Total Recordable Cases"" Rate:" "Please provide the Current ""Total Work Loss"" Rate:" "4c. Is your firm's recordable case rate worse than industry standard for two of the last three years? (Automatically Calculated)" "5. Has your firm received an OSHA Serious, Willful or Repeat violation in the last three years, regardless of appeal status? Yes or No" "6. Has your firm experienced a workplace fatality in the last three years? Yes or No" "If you answered ""No"" to every question above (4.c., 5 and 6), you do not need to complete Steps 2 or 3, below. " "If you answer ""Yes"" to any of the questions 4.c., 5 and 6, proceed to Step 2."