36E77619R0097-015.docx
DOCX document 13 KB Posted
- Attached to
- Construct Clean Core (VA-19-00058573) Federal contract opportunity
- Solicitation number
- 36E77619R0097
About this file
This document contains a contractor safety and environmental record evaluation form and information on a forthcoming federal contract solicitation. The evaluation form requests safety data from 2015 to 2018, including man hours, OSHA recordable incidents, days away from work rates, and serious violations. The related solicitation will be for construction services to build a clean core addition and renovate space at the Providence VA Medical Center in Rhode Island. The project involves constructing a new surgery suite within and adjacent to existing operating rooms, relocating certain areas, and adding an elevated clean core. The total project value is estimated between $5 million to $10 million. The solicitation will be a request for proposal conducted as a total small business set-aside for service-disabled veteran-owned small businesses. The contract period of performance is approximately 490 calendar days from notice to proceed. The pre-solicitation notice targets issuance on October 16, 2019.
36E77619R0097 Attachment 12 - Contractor Safety and Environmental Record Evaluation Form.docx
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36E77619R0097 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2015 |
| 2016 |
| 2017 |
| 2018 |
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.
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