Attachment 14 - Contractor Safety - Environmental Form.pdf
PDF 117 KB Posted
- Solicitation number
- 36C77623B0002
About this file
This form requests safety and environmental records from contractors. It asks for man hours, OSHA injury cases, days away from work rates, and serious violations over the past four years.
The related federal contract opportunity is solicitation number 36C77623B0002 for construction of EHRM infrastructure upgrades at the Grand Island Veterans Affairs Medical Center project number 636-21-701. The opportunity is issued by the Department of Veterans Affairs Technology Acquisition Center located in Austin, Texas. The description involves construction services for specified infrastructure upgrades. No further details are provided in the document.
View the file
Other files
Show all 41
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77622B0040
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.
Contractor Safety and Environmental Record Evaluation Form
File details come from the government source that posted it. Updated .