S02 - ATCH 32 - Contractor Safety - Environmental Form.pdf
PDF 117 KB Posted
- Solicitation number
- 36C77623B0049
About this file
This document contains a contractor safety and environmental record evaluation form and information about a related cancelled federal contract opportunity. The evaluation form requests contact information and safety data from a company's OSHA 300 forms including man hours, cases involving days away from work or restricted activity, days away restricted or transferred rate, and any serious, willful, or repeat OSHA violations from the past three years. The related cancelled federal contract opportunity was for construction and parking expansion at the Joliet CBOC from the Department of Veterans Affairs Technology Acquisition Center Austin. The solicitation number and name are provided.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0049
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.
Contractor Safety and Environmental Record Evaluation Form
File details come from the government source that posted it. Updated .