Northeast Data

New Staffing / Subcontract Agencies Working with Northeast Data

When initiating account setup with a new staffing, temporary worker, and / or subcontract agency, the below process must be followed. The process outlined below allows Northeast Data, Inc. to obtain complete and accurate account information for record keeping purposes. This also ensures that the agency’s safety practices and expectations align with that of Northeast Data, Inc.

Onboarding Requirements

Safety Qualification Package must be completed, returned to Northeast Data, Inc, and processed. This package may contain but is not limited to:

Approved agencies MUST have a Total Recordable Incident Rate (TRIR) of less than 1 and must be pre-approved by the owner of Northeast Data, Inc.

Annual Contract Renewal Requirements

The following must be completed annually:

Prior to Annual Contract renewal, the above-listed requirement will be reviewed by the owner of Northeast Data, Inc. to determine the continuation of approved agency status.

F1

Safety Qualification Form

Section 1 - General / Corporate Headquarters Information

Company Legal Name: ______________________________________________________________________________

Common Name (DBA): ______________________________________________________________________________

Physical Address (Street Address): _____________________________________________________________________

City: _________________________________________ State: _______________ Zip Code: _____________________

Phone No: _______________________ Mobile No: ________________________ Fax No: _______________________

Email Address: ______________________________________ Website: _____________________________________

Mailing / Branch Address (If different from above): _________________________________________________________

City: _________________________________________ State: _______________ Zip Code: _____________________

Federal Employer ID Number: _________________________________________________________________________

NAICS Codes: _______________ ________________ ________________ _________________ _______________

Submitted By: ____________________________________ Date: ________________ Phone: ___________________

Section 2 - Safety Information

In order to maintain compliance with OSHA CFR 1926.119, Process Safety Standard, please provide all of the following information requested herein. This will provide Northeast Data, Inc. with the necessary information to evaluate your safety performance as required by OSHA.

  1. Submit a copy of your firms OSHA forms 300 (log of Work-Related Injuries and Illnesses), 300A (Summary of Work-RelatedInjuries and Illnesses), 301 (Injury and Illness Incident Report) covering the last 3 years.

    2. Please Note: Employers with more than ten employees whose establishments are not classified as a partially exempt industry must record work-related injuries and illnesses using OSHA Forms 300, 300A, and 301. Partially exempt industries include establishments in specific low hazard retail, service, finance, insurance, or real estate industries and are listed in Appendix A to Subpart B of OSHA.

  2. Some firms are not required to complete the OSHA form No. 300 log, because they either have too few employees or areexempted by virtue of the services they perform. If you are not required to complete and OSHA 300 log, is it because yourfirm has too few employees?

    3. ☐Yes ☐ No ☐ N/A

  3. Or is it because your firm performs a service, which is exempted from completing an OSHA 300 log?

    4. ☐Yes ☐ No ☐ N/A

  4. If you do not complete and OSHA 300 log and you answered "NO"" to the above questions, please explain your answers.

    5. ______________________________________________________________________________________________________________________________________________________________________________________

    ______________________________________________________________________________________________________________________________________________________________________________________

    ______________________________________________________________________________________________________________________________________________________________________________________

  5. Submit from your insurance Agency (or state fund, if applicable) your EMR’s (Interstate and Intrastate) for the last three (3) rating periods. IF you do not have an interstate rating, obtain your Intrastate EMR’s. If Intrastate, indicate which state:

    6. _________________ Then complete the following data:

    (Note: Based on OSHA forms 300, 300A, and 301)

    Category 2023 2022 2021 Remarks
    Experience Modification Rate / EMR (Interstate)



    Experience Modification Rate / EMR> (Intrastate)



    Number of Hours Worked



    Number of OSHA Citations



    Number of Doctor Only Incidents



    Number of Recordable Incidents



    Medical Only Incidents



    Restricted Work Incidents



    Lost Time Incidents



    Number of Restricted Workdays



    Number of Lost Time Workdays



    Number of Fatalities



    Total Number of Injury & Illness Incidents



    Total Recordable Incident Rate* (TRIR)



    Days Away / Restricted or Transfer Rate** (DART)



    Lost Time Case Rate*** (LTCR)



    Lost Word Day Rate**** (LWDR)



    Severity Rate (SR) = Total Number of LWD / Total Number of Recordable Incidents



    Notes:

    * Total Recordable Incident Rate (TRIR)
    		 = [Total cases from lines G, H, I, and J x 200,000*] / Total hours worked in calendar year
    ** Days Away / Restricted, and Transferred Rate (DART)
    		 = [Total cases from lines H and I x 200,000] / Total hours worked in calendar year
    *** Lost Time Case or Incident Rate (LTCR)
    		 = [Total # of boxes checked in column H x 200,000] / Total hours worked in calendar year
    **** Lost Work Day Rate (LWDR)
    		 = [Total cases from lines G and H x 200,000] / Total hours worked in calendar year
  6. If your EMR is exactly 1.0 for any policy year, is it because your firm is (or was) too new of too small to have an EMR calculated?

    7. ☐Yes ☐ No ☐ N/A

Section 3 - Training

In order to maintain compliance with OSHA CFR 1926.119, Process Safety Standard, please provide all of the following information requested herein. This will provide Northeast Data, Inc. with the necessary information to evaluate your safety performance as required by OSHA.

  1. Is lift training completed annually?

    2. ☐Yes ☐ No ☐ N/A

  2. If “Yes”, the training is completed:

    3. ☐ Online ☐ In Person
    Training Facility or Website: ______________________________________

Section 4 - Organization Information

  1. List names and titles of Officers, Partners, and Principles.
    2. Name Title








Section 5 - Required Document Information and Attachments

Please check the items you have included:

  1. Attach any of the following data regarding your firm EMR:
    1. ☐ A letter from your insurance agent, insurance carrier / provider of State Fund (on their letterhead) verifying your EMR (Experience Modification Rating) for the last three (3) years; or
    2. ☐ Furnish a copy of the last year EMR Calculation Sheets which your insurance carrier should forward to you annually; or
    3. ☐ Furnish a copy of the page from your last year insurance policies showing the modification rate and the coverage period; or
    4. ☐ If you are in a “State Fund” state, (referred to as the “Monopolistic States”) Such as Ohio, West Virginia, Washington, or North Dakota furnish a copy of the state’s last year annual statement page showing the modification rate and the coverage period.
  2. ☐ Attached is a full copy of your company’s OSHA 300 logs and OSHA Summary Logs for the last three (3) years.

Section 6 - Acknowledgement

I declare under penalty of perjury that the above information, based on records available to me at this time, is true and accurate. The person signing below shall be an authorized officer of the company.

Signature: _______________________________________ Full Name: ______________________________________

Title: ___________________________________________ Date: __________________________________________

Email Address: ____________________________________ Phone Number: _________________________________

Note:We subscribe to a safety goal of Zero Incidents. We plan to work with contractors who share our safety philosophy of maintaining a work site which exhibits ZERO incident characteristics. Any contractor with an EMR greater than 1.0 or TRIR greater than 4.0 will be evaluated by the Project Manager and Safety Manager.

Please provide all of the required statistics or information requested herein. This will provide Northeast Data, Inc. with the necessary information to evaluate your safety performance as required by OSHA.

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