S02 - Attachment 9 - Contractor Safety and Environmental Record Form.docx

DOCX document 24 KB Posted

Attached to
36C77623B0064 EHRM San Antonio Infrastructure Upgrades - Construction
Solicitation number
36C77623Q0319
Issued by

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This document contains an attachment to a federal solicitation requesting safety and environmental records from prospective contractors. The attachment is a form for contractors to provide their OSHA 300 data from 2019 to 2022 including total man hours, days away from work cases, restricted duty cases, and DART rates. Contractors must also disclose any serious, willful, or repeat OSHA violations from the last three years and provide explanations for any violations. The related federal contract opportunity is solicitation number 36C77623Q0319 from the Department of Veterans Affairs for infrastructure upgrades at San Antonio EHRM facilities.

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ATTACHMENT 9 - Contractor Safety and Environmental Record Evaluation Form

Information provided below is current and applicable to Solicitation 36C77623B0064. Please include this completed form in your bid or proposal.

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.

ATTACHMENT 9 TO SOLICITATION 36C77623B0064 EHRM SAN ANTONIO INFRASTRUCTURE UPGRADES

File details come from the government source that posted it. Updated .