Attachment 7 - Contractor Safety - Environmental Form.pdf
PDF 189 KB Posted
- Solicitation number
- 36C77622B0043
About this file
This document contains a contractor safety and environmental record evaluation form for solicitation 36C77622B0043 to renovate the EHRM training room and administrative support space in Leavenworth, Kansas. The form requests the contractor's company information, OSHA 300 form data for the past four years including man hours, cases involving days away from work or restricted activity, and DART rates. It also asks for any serious, willful, or repeat OSHA violations in the past three years along with an explanation for any violations.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77622B0043
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
Utilizing your OSHA 300 Forms, please complete the following information:
Category 2018 2019 2020 2021
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 .