Attachment 15 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Attached to
- Y1DA--EHRM Training and Admin Space Support Construction - Kansas City VAMC Federal contract opportunity
- Solicitation number
- 36C77623B0020
About this file
This is an evaluation form for contractor safety and environmental records related to solicitation 36C77623B0020 for EHRM Infrastructure Upgrades at the Kansas City Veterans Affairs Medical Center. The form requests a company's name, address, phone number, email, contact information, and OSHA 300 data for the past four years including man hours, cases involving days away from work or restricted activity, and days away from work, restricted activity, or job transfer rates. Contractors must also disclose any serious, willful, or repeat OSHA violations within the last three years and provide an explanation for any violations.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0020 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.
File details come from the government source that posted it. Updated .