36E77618R0017-019.docx
DOCX document 13 KB Posted
- Attached to
- VISN 23 RF Room Upgrades Multi-Site Prep Construction - Install RF Equipment Federal contract opportunity
- Solicitation number
- 36E77618R0017
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36E77618R0017 ATTACHMENT 11 - CONTRACTOR SAFETY AND ENVIRONMENTAL RECORD EVALUATION FORM 02.docx
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36E77618R0017 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2014 |
| 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.
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