36E77619R0040-005.docx
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- Attached to
- Convert Dental Conference Room to Patient Rooms
- Solicitation number
- 36E77619R0040
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36E77619R0040 S02 - Attachment D - Contractor Safety and Environmental Record Evaluation Form.docx
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36E77618R0092 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2015 |
| 2016 |
| 2017 |
| 2018 |
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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