36C24818R0044-006.pdf

Past Safety and Environmental

VA24818R0044

OPTIONAL SAMPLE FORM FOR BIDDER/OFFEROR TO COMPLETE & SUBMIT

WITH BID/PROPOSAL

Pre-Award Contractor Evaluation Form

Company Name: ______________________________________________

Address: ____________________________________________________

Telephone: ______________________ Fax: ______________________

Email: ______________________________________________________

Contact: _____________________________________________________

1. Utilizing your OSHA 300 Forms, please complete the following information:

Category 2015 2016 2017 Number of man hours (jobsite and office).

Number of cases involving days away from work, restricted activity, or both (Column H and I of OSHA 300).

Days away, restricted, or transferred rate (# of days away, restricted, or transferred cases x 200,000/# of man hours) (DART Rate).

Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations. (Four serious, one repeat, or one willful disqualifies the contractor.)

Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page:

http://www.osha.gov/pls/publications/publication.html.

2. Provide your six-digit North American Industrial Classification System (NAICS) Code for this

Acquisition.__________________

3. Who administers your company’s Safety and Health Program?_____________________

4. Company Modification Rate (EMR) for the past 3 years. Note an EMR of greater than 1.0 disqualifies the contractor:

Signature ___________________ Date______________

VA24818R0044

Attachment 5 Past Safety and Environmental Form