S02 - Attachment 2 - Contractor Safety and Environmental Record Evaluation Form.pdf
PDF 107 KB Posted
- Attached to
- Project 614-18-115, Renovate Operating Rooms
- Solicitation number
- 36C24922R0015
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity to renovate operating rooms at a Department of Veterans Affairs medical center. The evaluation form requests contact information and safety data including hours worked, injury cases, and violation history from the past three years. It asks for NAICS code and details on the company's safety program administration and insurance experience modification rate. The related solicitation provides an opportunity to renovate operating rooms at a VA medical center in Memphis, Tennessee, requiring all necessary labor, materials, equipment, permits and licenses to complete the project in accordance with drawings and specifications.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24922R0015
Company Name: ____________________________
Address: ____________________________
Telephone: ____________________________
Email: ____________________________
Contact: ____________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 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.
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: 236220 – Commercial and Institutional Building Construction
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate
(EMR): ____________________________
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .