36E77619B0012-015.docx

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Attached to
Radiology Expansion (Construction) Prescott VAMC
Solicitation number
36E77619B0012
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This document provides information for a contractor safety and environmental record evaluation form related to solicitation number 36E77619B0012 for a Radiology Expansion construction project at the Northern Arizona VA Medical Center. The solicitation will be issued as an Invitation for Bid for a firm-fixed-price construction contract valued between $5 million and $10 million. The scope of work involves renovating and expanding an existing radiology area by demolishing approximately 3,000 square feet of an existing lab expansion and constructing a new optimized footprint with centralized waiting room, wide hallways, and sufficiently sized rooms. Ground level access and future capacity for a second story are desired design elements. The solicitation is a Service-Disabled Veteran-Owned Small Business set-aside to be issued on or around August 8, 2019 with all bids due on the date specified. The period of performance is approximately 425 calendar days from notice to proceed.

36E77619B0012 Attachment 14 - CONTRACTOR SAFETY AND ENV RECORD FORM.docx

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Contractor Safety and Environmental Record Evaluation Form

Information provide below is current and applicable to Solicitation 36E77619B0012 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:

Category
2016
2017
2018
2019

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 .