36E77619R0085-029.docx

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Attached to
Correct Building 5, 6 & 8 Water Infiltration D-B Dallas VANTHCS
Solicitation number
36E77619R0085
Issued by

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This document contains a contractor safety evaluation form and details of a federal solicitation opportunity. The safety evaluation form requests information on a contractor's man hours, OSHA recordable incidents, DART rates, and serious violations over the past three years to evaluate safety performance for solicitation 36E77619R0085.

The solicitation seeks a design-build contractor to investigate and correct water infiltration issues in buildings 5, 6, and 8 at the Dallas VA Medical Center. The scope of work includes inspecting basements for water intrusion points, sealing penetrations, installing waterproofing, and remediating damaged interior spaces. The opportunity will be conducted as a LPTA procurement and is set aside for SDVOSBs. The period of performance is 270 days from notice to proceed, with a construction budget between $1 million to $2 million. Questions are due to the issuing office by email only. The solicitation is expected to be released on July 10, 2019.

36E77619R0085 Attachment 5 - Contractor Safety And Environmental Record Evaluation Form.docx

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Contractor Safety and Environmental Record Evaluation Form

Information provide below is current and applicable to Solicitation 36E77619R0085 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 .