ATTACHMENT 11 - Contractor Safety - Environmental Form.docx

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Attached to
Y1DA--Expand Primary Care (Minor) Construction Iron Mountain
Solicitation number
36C77621B0005
Issued by

About this file

This document contains a contractor safety and environmental record evaluation form and details of a federal contract opportunity for the expansion and renovation of primary care facilities at a Department of Veterans Affairs medical center. The evaluation form requests safety and environmental data from 2017 to 2020, including man hours, OSHA recordable incidents, injury rates, and violations. The contract opportunity is a service-disabled veteran-owned small business set aside to design and construct a 10,000 square foot addition and renovate 1,100 square feet of an existing VA medical center in Michigan. The project scope includes architectural, site, structural, mechanical, electrical and other construction work. The solicitation will be issued as an invitation for bid evaluated based on the procedures in the solicitation. The North American Industry Classification code is 236220 and size standard is $39.5 million. The period of performance is approximately 546 calendar days.

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Contractor Safety and Environmental Record Evaluation Form

Information provide below is current and applicable to Solicitation 36C77621B0005 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:

Category
2017
2018
2019
2020

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 .