Attachment 14 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Attached to
- Y1DZ--EHRM Training and Admin Space Support Construction - Milwaukee, WI 695-21-703 Federal contract opportunity
- Solicitation number
- 36C77622B0017
About this file
This form requests safety and environmental records from contractors. It asks for the company name, address, phone numbers, email, and contact. It then requests OSHA 300 form data for the past four years including total man hours, cases involving days away from work or restricted activity, days away from work rate, and any serious, willful, or repeat OSHA violations along with explanations.
The related federal contract opportunity is solicitation number 36C77622B0017 for the construction of training and administrative space at the VA Medical Center in Milwaukee, Wisconsin. Supporting documents provide additional details on the required scope of work. The contracting agency is the Department of Veterans Affairs Technology Acquisition Center located in Austin, Texas.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77622B0017 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 .