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S. ATOMIC ENERGY COMMTSSIOn
WORKSHEET FOR EVALUATING INDUSTRIAL SAFETY RECORD
This worksheet may be used within an organization to test eligibility of its
own record or to set goals for the year ahead, Or, it may be used as an application form for records covering two or more calendar years, as provided
in Item 1 on the reverse side,
NOTE !} See Instructions on next pages, numbered to correspond with items
below.
Organization
Location
Frea, Rate
1.
Sev. Rate
Current experience, for calendar year(s)
Employee hours in current experience
2,
Rates for
atomic energy group
3.
Own previous experience: years
4.
Determination of "Par" (a) Add lines 2 and 3;
(b) Take half of line 4K,
These are "Par" rates
5.
Percent which current rates are under "Par"
_
(Unit does not qualify if rates are over "Par")
6,
Percent under "Par" required to qualify
7.
Do current rates qualify for:
(a)
(b)
(a)
(b)
8.
Award of Merit (See Table)
Award of Honor (Add 2 to percent above)
-
Z
g¢
Z
-
&¢
- 10%
- 30%
Award of Merit (Is the decrease on line 5
equal to or greater than that on line 6a? Yes No__
Award of Honor (Is the decrease on line 5
Yes__
No
equal to or greater than that on line 6b? YesNo__ Yes__
No__
(a) If current rates (line 1) are higher than the
corresponding previous rates (line 3), show
percent increases, (If decrease, Leave blank) +
g
+
“&
(b) Are the increases (line 8a) less than maximum
allowable: (If decreases, check "Yes")
(1) For Award of Merit (less than 30%)
(2)
For Award of Honor (less than 10%)
Signed
Date
YesNo Yes. No__
YesNo__ Yes_ No_
Title
_
(over)
iY
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