Attachment F3-2 – Environment, Safety and Health Worksheet
5. For companies exempt from record keeping requirements per 29 CFR 1904.1 (ten or fewer
employees), complete items 1 and 3 above and summarize the cause of the injuries/illnesses
for the past three (3) years, including the current year, on a separate attachment to this form.
Additionally, include corrective actions taken to prevent re-occurrence.
6. Check your type of work for the most recent 3 year period:
Non-Residential Building, include dates:
Heavy (Non-Highway) Construction, include dates:
Mechanical, include dates:
Electrical, include dates:
Other (State type and date):
7. List key Safety and Health personnel planned for this project. Please list name and expected
position.
NAME POSITION
8. List key Environmental personnel planned for this project. Please list name and expected
position.
NAME POSITION
9. Environmental Record
Has your firm been subject to any environmental enforcement proceedings before a federal or
state agency within the last five (5) years? ____ If Yes, for each proceeding provide the name
of the agency, the nature of the proceeding, the charge(s) and the result on an attachment to
this form.
Has your firm violated or exceeded any federal or state environmental standard, requirement,
regulation or statute within the last three (3) years? ____ If Yes, for each violation give a brief
description of the nature of the violation on an attachment to this form.
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*If Subcontractor does not meet threshold for being assigned an Experience Modification Rate, the
Subcontractor's Workers' Compensation Insurance Carrier should document this in a letter along with the
number of claims against the workers' compensation policy over the last three years in lieu of EMR data.
NOTE: This form is for evaluation purposes only and will not be a part of a Subcontract.
