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<br />APPENDIX A <br />CONTRACTOR SAFETY OIIESTTONNAIRE <br />' 1. COMPANY <br />NAME : DATE <br />' ADDRESS: <br />' CITY: STATE: ZIP: <br />2. PRIMARY TYPE OF BIISINESS/WORK/SERVICE: <br />PLEASE CHECK ONE: _10 OR LESS EMPLOYEES IN COMPANY <br />MORE THAN 10 EMPLOYEES IN COMPANY <br />NOTE: ALL CONTRACTORS PLEASE PROVIDE THE FOLLOWING <br />INFORMATION OR, IF NOT AVAILABLE, SKIP TO ITEM #15 AND <br />ATTACH APPROPRIATE DOCDMENTATION. <br />LIST ANY POTENTIAL SIGNIFICANT HAZARDS OF WORK TO BE <br />PERFORMED <br />1 <br />(ADDITIONAL SHEET MAY BE ATTACHED AS NECESSARY) <br />3. SAFETY CONTACT: TITLE: <br />' PHONE: <br /> 4. worker's Compensation <br />Insurance Company: <br /> Expiration date of current policy: <br /> 5. List your Injury/Illness Incident Rate (IIR) and Severity Rate <br /> (SR) as shown below: <br /> Calculate the IIR using the total number of injuries and <br />' illness requiring attention by a physician in the following <br /> formula; <br /> <br /> IIR = Total Iniur ies and Illnesses x 200. 000 <br /> Total Employee-Hours Worked* <br />' Calculate the SR using the total number of lost and restricted <br /> workdays due to injuries and illness using the following <br /> formula; <br />' SR = Total Lost and Restricted Workdays x 200.000 <br /> <br />' A-1 <br />