S06 - Att 1 Safety Record.pdf

Solicitation #: 36C25224B0004

PRE-AWARD CONTRACTOR SAFETY AND ENVIRONMENTAL

RECORD EVALUATION FORM

Company Name: ______________________________________________

Address: _____________________________________________________

Telephone: ______________________ Fax: ________________________

Email: _______________________________________________________

DUNS Number: ___________________ UEI Number :________________

Contact: ______________________________________________________

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

Category 2020 2021 2022 2023

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.

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’s Insurance Experience Modification Rate (EMR): _____________ http://www.osha.gov/pls/publications/publication.html