Attachment 17 - CONTRACTOR SAFETY AND ENV RECORD EVAL FORM.docx
DOCX document 14 KB Posted
- Solicitation number
- 36E77620R0054
About this file
This document contains a contractor safety and environmental record evaluation form and information on a related federal contract opportunity for an overhead page and nurse call system design-build project at the Fort Meade VAMC. The evaluation form requests a contractor's OSHA 300 form information for the last four years, including man hours, days away from work cases, DART rates, and any serious OSHA violations. The federal contract opportunity is a service-disabled veteran-owned small business set aside with a response due date and award date to be specified in the solicitation. The project description, specifications, and drawings will be attached to the solicitation posted on SAM.gov. The period of performance is approximately 335 calendar days with a construction magnitude estimated between $2,000,000 to $5,000,000.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36E77620R0054 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2017 |
| 2018 |
| 2019 |
| 2020 |
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 .