36C24818R0186-0005004.docx

Past Safety and Environmental Record

(SAMPLE FORM FOR BIDDER/OFFEROR TO COMPLETE & SUBMIT WITH

PHASE I PROPOSAL)

Pre-Award Contractor Evaluation Form Company Name:

Address:

Telephone: Fax:

Email:

Contact:

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

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.

Provide your six-digit North American Industrial Classification System (NAICS) Code for this Acquisition: __ Who administers your company’s Safety and Health Program? ____________________________ Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor): ___________

Signature / Date