Attachment 11 - Contractor Safety - Environmental Form.docx
DOCX document 21 KB Posted
- Attached to
- Y1DA--Copy of EHRM Infrastructure Upgrades - Construction - Omaha VAMC DUPLICATE OF 36C776230036
- Solicitation number
- 36C77623B00361
About this file
This document contains a contractor safety and environmental record evaluation form and details of a related federal contract opportunity for infrastructure upgrades at the Omaha Veterans Affairs Medical Center.
The evaluation form requests contact information and safety data from the past four years, including total man hours, OSHA recordable incidents, days away from work rates, and any serious violations. Bidders must provide explanations for any OSHA violations in the previous three years.
The related federal contract opportunity is solicitation number 36C77623B00361 to provide construction services for EHRM infrastructure upgrades at the Omaha VAMC. The solicitation was issued by the Department of Veterans Affairs Technology Acquisition Center located in Austin, Texas. No further details are provided on the required scope of work, response deadline, period of performance, or place of performance.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77622B0063 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 .