Attachment 10 Contractor Safety and Environmental Record Evaluation Form.pdf
PDF 170 KB Posted
- Solicitation number
- 36C10F20R0069
About this file
This document includes a contractor safety and environmental record evaluation form and information about a federal contract opportunity for the Ohio Western Reserve National Cemetery Phase 3 Development.
The evaluation form requests safety and compliance information from contractors including OSHA 300 and 300A forms from 2016 to 2019 with injury rates, any serious OSHA violations in the last three years, NAICS code, safety program administrator, and experience modification rate. The related federal contract opportunity is a tiered solicitation from the Department of Veterans Affairs for the cemetery development. The tiers provide priority to SDVOSB, VOSB, small business including HUBZone small businesses, and then large businesses if no award can be made at the higher tiers. The solicitation includes a notice of tiered evaluations.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C10F20R0069
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
Utilizing your OSHA 300 Forms, please complete the following information:
Category 2016 2017 2018 2019
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 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
Contractor Safety and Environmental Record Evaluation Form
File details come from the government source that posted it. Updated .