Attachment 12- Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C77624B0006
About this file
This document is a contractor safety and environmental record evaluation form for a solicitation from the Department of Veterans Affairs Technology Acquisition Center Austin. The form requests a contractor's OSHA 300 forms from 2019 through 2022, including the number of man hours, number of cases involving days away from work or restricted activity, days away from work rate, and any serious, willful, or repeat OSHA violations in the last three years along with explanations. The related solicitation is for project 202-318-REHAB building construction at TOGUS, Maine under solicitation number 36C77624B0006. The form collects safety and environmental record information from prospective contractors to evaluate their eligibility for the construction project.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to the Solicitation 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 .