Attachment 8 - Contractor Safety and Environmental Record Evaluation Form.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C77622R0058
About this file
This document contains a contractor safety and environmental record evaluation form. The form requests information from contractors such as company name, address, contact details, number of man hours in 2015-2018 for both jobsite and office work, number of OSHA recordable injury cases involving days away from work or job transfer/restriction for 2015-2018, days away from work rate calculated using OSHA formula for 2015-2018, and any serious, willful or repeat OSHA violations in the last three years along with explanations. Contractors are to provide this safety record information for evaluation as part of solicitation 36E77620R0030 to support infrastructure upgrades at the Salt Lake City VA Medical Center.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36E77620R0030 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.
File details come from the government source that posted it. Updated .