Attachment 13 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Attached to
- 36C77623R0039 - Y1DZ - New Mental Health Building Phase 2 Minor Construction - Providence, RI
- Solicitation number
- 36C77623R0039
About this file
This document contains a contractor safety and environmental record evaluation form and details of a federal contract solicitation. The solicitation is for a single firm-fixed-price contract to provide general construction services for the Construct Mental Health Phase 2 project at the Providence VA Medical Center in Providence, Rhode Island. Services shall include general construction, alterations, civil site work, finishes, HVAC, electrical, plumbing, fire alarm and suppression, security, and other items as outlined in the construction documents to complete the new mental health building phase of the project. Interested contractors must complete the safety and environmental record evaluation form providing OSHA record information from 2019 through 2022 as well as details of any serious, willful, or repeat OSHA violations in the last three years. The solicitation is issued by the Department of Veterans Affairs Technology Acquisition Center Austin for the Veterans Health Administration Program Contracting Activity Central.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623R0039 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 .