6 - Contractor Safety and Environmental Record.docx
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- Solicitation number
- 36C77623B0038
About this file
This is an evaluation form for a contractor's safety and environmental record submitted in response to solicitation number 36C77623B0038 from the Department of Veterans Affairs Technology Acquisition Center Austin. The form requests a contractor's OSHA 300 Forms for the years 2019 through 2022, including the number of man hours, number of cases involving days away from work or restricted activity, days away restricted or transferred rate, and any serious, willful, or repeat OSHA violations in the last three years along with an explanation for any violations.
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Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C77623B0038 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: _____________________________________________________
Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2019 |
| 2020 |
| 2021 |
| 2022 |
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.
File details come from the government source that posted it. Updated .