MNSTAR application general information

Site/company name:
Site address:
Site manager (name and title):
Site MNSTAR contact (name and title):
Phone number(s):

Company/corporate name (if different from above)

Corporate MNSTAR contact: (if applicable -- name and title)
Address:
Phone number(s):

Collective bargaining representative(s)

Union name and number of Local chapter:

Name of union contact:

Union address:

Union phone number(s):

Number of employees

Site employees:

Temporary employees (routinely on the site):

Contract employees
(routinely on the site):

Type of work performed and/or products produced:
Site's standard industrial classification (SIC) code (a three- or four-digit number):

Injury rates

For regular site-employees, including temporary employees you supervise, provide the data requested in the following charts for each of the last three calendar years, plus the average for the three years combined. (Small employers may use the best three out of four prior years.)
For contractors whose employees worked 1,000 or more hours on your site in any calendar quarter, provide one combined set of data on the charts below reflecting the contractor employee hours worked at your site. (Do not include the hours the contractor employees worked on other sites.)

Total recordable case rate

Site employees				Contract employees
Year	Hours worked	Recorded injuries and illnesses	Rate¹	Hours worked	Recorded injuries and illnesses	Rate



Site three-year average²:
BLS industry average:

Lost-workday case rates³

Site employees				Contract employees
Year	Hours worked	Lost- and restricted-workday injuries/illnesses	Rate⁴	Hours worked	Recorded injuries and illnesses	Rate



Site three-year average:
BLS industry average:

¹Total recordable case rates (TRCR) are calculated (N/EH) x 200,000 where:

N = number of recorded injuries in one year.
EH = total number of hours worked by all employees in one year.
200,000 = equivalent to 100 full-time workers working 40-hour weeks, 50 weeks a year.

²Three-year averages are calculated by totaling the hours worked (EH) and the number of injuries/illnesses (N) and using these totals in the formula.
³Includes restricted- and lost-workday injuries and illnesses.
⁴Calculations are the same as the TRCR except N = the number of lost and restricted cases.

Union name and number of Local chapter:
Name of union contact:
Union address:
Union phone number(s):

Site employees:
Temporary employees (routinely on the site):
Contract employees (routinely on the site):