Attachment 13 - CONTRACTOR SAFETY AND ENV RECORD FORM.docx
DOCX document 13 KB Posted
- Solicitation number
- 36E77620B0003
About this file
This document includes an evaluation form for contractor safety records and a solicitation notice for construction services. The evaluation form requests a contractor's OSHA 300 forms and safety metrics including man hours, injury cases, days away from work rates, and OSHA violations for the past four years.
The solicitation seeks bids for the construction of an expanded primary care clinic at the Newington VA Medical Center in Connecticut. The project scope involves renovating approximately 25,000 square feet across multiple buildings to expand primary care space and relocate other medical services. The solicitation will be issued as an Invitation for Bid to Service-Disabled Veteran-Owned Small Businesses only, with a budget between $5-10 million. The anticipated period of performance is 600 days. The response deadline is not provided. The Department of Veterans Affairs is the contracting agency.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36E77619B0020 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2016 |
| 2017 |
| 2018 |
| 2019 |
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 .