Attachment 10 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Attached to
- Y1DZ--Nutrition & Food Servicesand Eye/ PT Clinic Addition - - Construction - Louis A. Johnson VAMC
- Solicitation number
- 36C77623B0031
About this file
This document contains a contractor safety and environmental record evaluation form and information about a related federal contract opportunity for construction services. The evaluation form requests information from contractors such as company details, OSHA recordable incident rates from 2019 to 2022, and any serious OSHA violations in the past three years.
The related federal contract opportunity is solicitation number 36C77623B0031 from the Department of Veterans Affairs Technology Acquisition Center Austin for a nutrition and food services addition and eye/PT clinic addition at the Louis A. Johnson VA Medical Center. Contractors are required to submit safety and environmental records using the provided evaluation form to be considered for this construction services contract.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0027 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2019 |
| 2020 |
| 2021 |
| 2022 |
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 .