Attachment 14 - Contractor Safety and Environmental Record Evaluation Form.docx
DOCX document 14 KB Posted
- Attached to
- Y1DA--Iowa City | EHRM Infrastructure Upgrades
- Solicitation number
- 36C77622R0094
About this file
This form requests safety and environmental record information from contractors for the solicitation numbered 36C77622R0061. It asks for the company name, address, phone numbers, email, and contact person. It then requests man hours, OSHA recordable cases, days away from work or restricted activity rates, and details on any OSHA violations over the past three years to evaluate contractor safety performance.
The related solicitation is numbered 36C77622R0094 and is an RFP from the Department of Veterans Affairs Technology Acquisition Center Austin for design-bid-build infrastructure upgrades to the Iowa City EHRM facility. It provides opportunity details but no further requirements or pricing are specified in the provided information.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77622R0061 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 .