36C25620R0073-008.docx

FOR OFFICIAL USE ONLY

36C25620R0073

Exhibit A Contractor Evaluation Form Construction Safety

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 may disqualify 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. Who administers your company’s Safety and Health Program?

3. Company’s current Insurance Experience Modification Rate (EMR):____________________________