. CULL AbeDAU (1-53) U. f 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 fa | DOMARCHIVES