+-----------------+--------------+---------+----------+----+----+----+
| **Subcontractor |              |         |          |    |    |    |
| Monthly Safety  |              |         |          |    |    |    |
| Report**        |              |         |          |    |    |    |
+-----------------+--------------+---------+----------+----+----+----+
| Company Name:   | Accounting   | Subcon  |          | B  |    |    |
|                 | Month        | tractor |          | EA |    |    |
|                 | Ending:      | Safety  |          | Co |    |    |
|                 |              | St      |          | nt |    |    |
|                 |              | atistic |          | ra |    |    |
|                 |              | C       |          | ct |    |    |
|                 |              | ontact: |          | N  |    |    |
|                 |              |         |          | o: |    |    |
|                 |              | Phone   |          |    |    |    |
|                 |              | Number: |          |    |    |    |
+-----------------+--------------+---------+----------+----+----+----+
| **Employment    |              | **Total |          |    |    |    |
| Data**          |              | for the |          |    |    |    |
|                 |              | Month** |          |    |    |    |
+-----------------+--------------+---------+----------+----+----+----+
| 1\. Total       |              |         |          |    |    |    |
| Number of       |              |         |          |    |    |    |
| Subcontractor   |              |         |          |    |    |    |
| Individuals on  |              |         |          |    |    |    |
| site            |              |         |          |    |    |    |
+-----------------+--------------+---------+----------+----+----+----+
| 2\. Total Hours |              |         |          |    |    |    |
| Worked on site  |              |         |          |    |    |    |
| by              |              |         |          |    |    |    |
| Subcontractor   |              |         |          |    |    |    |
| Individuals     |              |         |          |    |    |    |
+-----------------+--------------+---------+----------+----+----+----+
| **Occupational  |              | **      | **In     |    | ** |    |
| Injury &        |              | Total** | dividual |    | Da |    |
| Illness Data**  |              |         | Name**   |    | te |    |
|                 |              |         |          |    | ** |    |
+-----------------+--------------+---------+----------+----+----+----+
| 3\. Number of   |              |         |          |    |    |    |
| new             |              |         |          |    |    |    |
| Occupational    |              |         |          |    |    |    |
| Injuries &      |              |         |          |    |    |    |
| Illnesses       |              |         |          |    |    |    |
| Cases, per 29   |              |         |          |    |    |    |
|                 |              |         |          |    |    |    |
| CFR 1904.5 and  |              |         |          |    |    |    |
| 1904.6 (Note: A |              |         |          |    |    |    |
| completed form  |              |         |          |    |    |    |
| 231.01/DOE      |              |         |          |    |    |    |
|                 |              |         |          |    |    |    |
| F 5484.3 must   |              |         |          |    |    |    |
| be submitted    |              |         |          |    |    |    |
| for each case   |              |         |          |    |    |    |
| listed, per PRD |              |         |          |    |    |    |
| 1003            |              |         |          |    |    |    |
|                 |              |         |          |    |    |    |
| Section 3.5.4)  |              |         |          |    |    |    |
+-----------------+--------------+---------+----------+----+----+----+
| 4.  Number of   |              |         |          |    |    |    |
|                 |              |         |          |    |    |    |
|    Occupational |              |         |          |    |    |    |
|     Injuries &  |              |         |          |    |    |    |
|     Illnesses   |              |         |          |    |    |    |
|     classified  |              |         |          |    |    |    |
|     as OSHA     |              |         |          |    |    |    |
|                 |              |         |          |    |    |    |
| Recordable, per |              |         |          |    |    |    |
| 29 CFR 1904.7   |              |         |          |    |    |    |
| through 1904.12 |              |         |          |    |    |    |
+-----------------+--------------+---------+----------+----+----+----+
| 5.  Number of   |              | \#      |          |    |    |    |
|                 |              | Lost:   |          |    |    |    |
|    Occupational |              |         |          |    |    |    |
|     Injury &    |              | \#      |          |    |    |    |
|     Illness     |              | Rest    |          |    |    |    |
|     Cases       |              | ricted: |          |    |    |    |
|     resulting   |              |         |          |    |    |    |
|     in Days     |              |         |          |    |    |    |
|     Away,       |              |         |          |    |    |    |
|     Restricted, |              |         |          |    |    |    |
|     Or Transfer |              |         |          |    |    |    |
|     (DART), per |              |         |          |    |    |    |
|     29 CFR      |              |         |          |    |    |    |
|                 |              |         |          |    |    |    |
|    1904.7(b)(3) |              |         |          |    |    |    |
|     and (4)     |              |         |          |    |    |    |
+-----------------+--------------+---------+----------+----+----+----+
| 6.  Number of   |              | \#      |          |    | #L | #R |
|     Days Away,  |              | Lost:   |          |    | WD | WD |
|     Restricted, |              |         |          |    |    |    |
|     and/or      |              | \#      |          |    |    |    |
|     Transferred |              | Rest    |          |    |    |    |
|     (DART), per |              | ricted: |          |    |    |    |
|     29 CFR      |              |         |          |    |    |    |
|                 |              |         |          |    |    |    |
|    1904.7(b)(3) |              |         |          |    |    |    |
|     and (4)     |              |         |          |    |    |    |
+-----------------+--------------+---------+----------+----+----+----+
| 7.  Number of   |              |         |          |    |    |    |
|     DART Cases  |              |         |          |    |    |    |
|     continuing  |              |         |          |    |    |    |
|     to accrue   |              |         |          |    |    |    |
|     Days Away,  |              |         |          |    |    |    |
|     Restricted, |              |         |          |    |    |    |
|     and or      |              |         |          |    |    |    |
|     Transfer at |              |         |          |    |    |    |
|     the time of |              |         |          |    |    |    |
|     this report |              |         |          |    |    |    |
|     submittal   |              |         |          |    |    |    |
+-----------------+--------------+---------+----------+----+----+----+
| 8\. Number of   |              |         |          |    |    |    |
| Fatalities, per |              |         |          |    |    |    |
| 29 CFR          |              |         |          |    |    |    |
| 1904.7(b)(2)    |              |         |          |    |    |    |
+-----------------+--------------+---------+----------+----+----+----+
| Subcontractor   |              |         |          |    |    |    |
| shall provide   |              |         |          |    |    |    |
| any update(s)   |              |         |          |    |    |    |
| to previously   |              |         |          |    |    |    |
| reported safety |              |         |          |    |    |    |
| statistics      |              |         |          |    |    |    |
| below:          |              |         |          |    |    |    |
|                 |              |         |          |    |    |    |
| Month being     |              |         |          |    |    |    |
| updated:        |              |         |          |    |    |    |
| \_\_\_\_\       |              |         |          |    |    |    |
| _\_\_\_\_\_\_\_ |              |         |          |    |    |    |
| \_\_\_\_\_\_\_\ |              |         |          |    |    |    |
| _\_\_\_\_\_\_\_ |              |         |          |    |    |    |
|                 |              |         |          |    |    |    |
| Identify and    |              |         |          |    |    |    |
| explain any     |              |         |          |    |    |    |
| changes:        |              |         |          |    |    |    |
+-----------------+--------------+---------+----------+----+----+----+