Attachment 15 - Contractor Safety - Environmental Form.docx

DOCX document 14 KB Posted

Attached to
Y1DA--EHRM Infrastructure Upgrade Construction Fort Meade VAMC
Solicitation number
36C77622B0055
Issued by

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This document contains a contractor safety and environmental record evaluation form for solicitation 36C77622B0055 for EHRM infrastructure upgrades at the Fort Meade VAMC. The form requests contact information and safety data including man hours, OSHA recordable incidents, days away from work rates, and serious violations over the past four years. Contractors must attach explanations for any OSHA violations in the last three years. The solicitation is for construction services to upgrade infrastructure at the Veterans Affairs Medical Center located at Fort Meade. The soliciting agency is the Department of Veterans Affairs Technology Acquisition Center in Austin.

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Contractor Safety and Environmental Record Evaluation Form

Information provide below is current and applicable to Solicitation 36C77622B0055 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 .