Attachment 13 - Contractor Safety - Env Rec Eval Form.docx

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Attached to
Y1DZ--Expand Mental Health Clinic Building 90, Tucson AZ
Solicitation number
36E77620B0008
Issued by

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This document contains a contractor safety evaluation form and details of a federal contract opportunity. The contractor safety form requests information on man hours, OSHA recordable incidents, injury rates, and safety violations from the past three years.

The federal contract opportunity is a solicitation from the Department of Veterans Affairs to expand a mental health clinic building at the Southern Arizona VA Health Care System. The solicitation will be issued as an Invitation for Bid evaluated based on procedures in the solicitation. This will be a total Service-Disabled Veteran-Owned Small Business set-aside contract for general construction work including demolition, site utilities, and architectural, structural, mechanical, plumbing and electrical work. The period of performance is approximately 600 calendar days from notice to proceed, and the estimated value is between $2,000,000 and $5,000,000. Questions must be submitted in writing by a specified date.

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Contractor Safety and Environmental Record Evaluation Form

Information provide below is current and applicable to Solicitation 36E77620B0006 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 .