S02 ATT 10 Contractor Safety-Enviro Form.pdf
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- Solicitation number
- 36C77623R0050
About this file
This document contains a Contractor Safety and Environmental Record Evaluation Form and information about a related federal contract opportunity. The evaluation form requests safety and environmental record information from prospective contractors, including man hours, OSHA injury cases, DART rates, and serious violations over the past four years. The related solicitation is number 36C77623R0050 from the Department of Veterans Affairs for construction of a Women's Health Clinic at the Manchester VAMC, with responses due on an unspecified date. Relevant details about required products, services, pricing, or timelines are not provided.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623R0050
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 .