+-------------------------------------------+--------------------------+
| **SUBCONTRACT SAFETY PERFORMANCE REPORT** | ***Subcontractor shall   |
|                                           | submit this form to the  |
|                                           | Subcontract Technical    |
|                                           | Representative (STR)     |
|                                           | before the third day of  |
|                                           | each month. STR must     |
|                                           | ensure report is         |
|                                           | complete.***             |
+-------------------------------------------+--------------------------+
|                                           |                          |
+-------------------------------------------+--------------------------+
|                                           | REPORTING MONTH          |
|                                           |                          |
|                                           |                          |
+-------------------------------------------+--------------------------+
| REPORTING SUBCONTRACTOR                   | SUBCONTRACT NUMBER       |
|                                           |                          |
|                                           |                          |
+-------------------------------------------+--------------------------+
| BWXT Y-12 SUBCONTRACT STR                 | STR PHONE NUMBER         |
|                                           |                          |
|                                           |                          |
+-------------------------------------------+--------------------------+

  --------------------------------- -------------------------------------
  **TOTAL HOURS WORKED THIS MONTH**      

  **FIRST AID CASES**                    

  **RECORDABLE CASES**                   

  **LOST WORKDAY CASES**                 
  --------------------------------- -------------------------------------

+----------------------------------+-------------------+---------------+
| REPORT SUBMITTED BY              | PHONE NUMBER      | DATE OF       |
|                                  |                   | REPORT        |
|                                  |                   |               |
|                                  |                   |               |
+----------------------------------+-------------------+---------------+
| COMMENTS                         |                   |               |
|                                  |                   |               |
|                                  |                   |               |
+----------------------------------+-------------------+---------------+

+----------------------------------------+----+------------------------+
| ## FOR STR USE                         |    |                        |
+----------------------------------------+----+------------------------+
| SUBCONTRACT TYPE                       | #  | # Submit comple        |
|                                        |  S | ted report to: Subcont |
| CONSTRUCTION SERVICES                  | TR | ractSafety@y12.doe.gov |
|                                        | :  |                        |
+----------------------------------------+----+------------------------+