Appendix 2- CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL- 589-23-108JC- Issued.pdf
PDF 178 KB Posted
- Attached to
- Z2DA--657-23-108JC, FCA - Repair Air Handler AC-1 (VA-25-00052824) John J. Cochran Veterans Hospital
- Solicitation number
- 36C25525R0049
About this file
Appendix 2 is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C25525R0049, which requires contractors to provide detailed safety performance information. The form requests companies to document their safety metrics over four years (2021-2024), including total man-hours, workplace injury/absence cases, Days Away, Restricted, or Transferred (DART) rates, and any OSHA violations. Contractors must also attach their OSHA 300 and 300a Forms, provide their six-digit NAICS code, and identify who administers their company's Safety and Health Program. This document appears to be a pre-qualification assessment to evaluate a contractor's safety record for a VA construction project at the John J. Cochran Veterans Hospital involving air handler repair and associated ductwork modifications.
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Text version
APPENDIX 2:
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C25525R0049:
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2021 2022 2023 2024
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.
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
2. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program?
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .