ATTACHMENT 11 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Attached to
- Y1AZ--EHRM Infrastructure Upgrades Construction - Pine Ridge Federal contract opportunity
- Solicitation number
- 36C77622B0041
About this file
This document contains a contractor safety and environmental record evaluation form and details of a federal contract opportunity for infrastructure upgrades at a VA facility in Pine Ridge, South Dakota. The form requests safety data from the past four years, including total man hours, OSHA-recordable incidents, days away from work rates, and serious violations. The contract opportunity, issued by the VA Technology Acquisition Center, involves electrical, HVAC, plumbing, and communications infrastructure upgrades and renovations. Work must comply with Tribal Employment Rights Office requirements and is subject to restricted daily construction hours at the remote location.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C77622B0041 0003.pdf | ||
| Technical Questions - FINAL - Pine Ridge 8-3-22.pdf | ||
| 36C77622B0041 0002.pdf | ||
| 36C77622B0041 0001.pdf | ||
| ATTACHMENT 10 - Construction Wage Rates - Bennett 7-1-22.pdf | ||
| Site Visit Sign-in Sheet - Pine Ridge 6-29-22.pdf | ||
| ATTACHMENT 1 - Specifications Vol 1.pdf | ||
| ATTACHMENT 2 - Specifications Vol 2.pdf | ||
| ATTACHMENT 4 - Drawings.pdf | ||
| ATTACHMENT 8 - COVID-19 Safety Protocols 12-14-21.pdf | ||
| ATTACHMENT 9 - Limitations on Subcontracting - Construction.docx | DOCX document | |
| ATTACHMENT 10 - Construction Wage Rates - Bennett 2-25-22.pdf | ||
| ATTACHMENT 12 - Site Visit Instructions.pdf | ||
| ATTACHMENT 3 - Scope of Work.pdf | ||
| ATTACHMENT 5 - ICRA-PCRA Risk Assessment.pdf | ||
| 36C77622B0041 - 6-13-22.pdf | ||
| ATTACHMENT 6 - Brand Name Justification - Pine Ridge.pdf | ||
| ATTACHMENT 7 - Cutsheets.zip | ZIP file |
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77622B0041 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 .