VA250-17-R-0594-042.docx

Pre-Award Contractor Safety and Environmental Record Evaluation Form

Information provided below is current and applicable to Solicitation VA250-17-R-0594

Company Name: Address: Telephone: Fax: Email: Contact:

1. Utilizing your OSHA 300 Forms, please complete the following information:

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.

Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.

2. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition:

3. Who administers your company’s Safety and Health Program?

4. Company’s Insurance Experience Modification Rate (EMR):