Attachment 11 Contractor Safety and Environmental Record Evaluation Form.pdf
PDF 115 KB Posted
- Solicitation number
- 36C10F20R0042
About this file
This document contains a contractor safety and environmental record evaluation form and information on a related federal contract opportunity for the Massachusetts National Cemetery Phase 4 Expansion project. The evaluation form requests contractors provide man hours, OSHA recordable incidents, and serious violations for the past four years. The related solicitation is for tiered evaluation of approximately 20 acres of land development and 12,000 grave sites at the Massachusetts National Cemetery in Bourne, issued by the Department of Veterans Affairs Office of Construction and Facilities Management under solicitation number 36C10F20R0042. Relevant details include the project scope, agency involvement, and evaluation criteria relating to contractor safety performance.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation __________________
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.
Contractor Safety and Environmental Record Evaluation Form
File details come from the government source that posted it. Updated .