ATTACHMENT 10 - Contractor Safety - Environmental Form.docx

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Attached to
Y1AZ--EHRM Training and Administrative Support Space - Oklahoma City
Solicitation number
36C77623B0008
Issued by

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This document contains a contractor safety and environmental record evaluation form and details of a federal contract solicitation. The solicitation, number 36C77623B0008, is from the Department of Veterans Affairs Technology Acquisition Center Austin to renovate approximately 7,700 square feet of existing space at the Oklahoma City VA Health Care System for use as administration and training space to support the deployment of new Cerner EHRM equipment and software. The renovation project will furnish all labor, tools, materials, equipment, and supervision needed. The evaluation form requests a contractor's OSHA 300 form information for the last four years, including man hours, cases involving days away from work or job transfer, and days away from work rate. It also asks for any serious, willful, or repeat OSHA violations in the last three years along with an explanation for any violations.

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Contractor Safety and Environmental Record Evaluation Form

Information provide below is current and applicable to Solicitation 36C77623B0008 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:

Category
2018
2019
2020
2021

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 .