ATTACHMENT 18 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Attached to
- Y1AZ--EHRM Infrastructure Upgrades Construction - Iron Mountain Federal contract opportunity
- Solicitation number
- 36C77622B0018
About this file
This document contains a contractor safety and environmental record evaluation form and details of a federal contract opportunity for infrastructure upgrades at an Iron Mountain VA medical center. The evaluation form requests a contractor's OSHA 300 form information for the past four years, including total man hours, days away from work cases, restricted activity cases, and the days away, restricted or transferred rate. It also asks for any serious, willful or repeat OSHA violations in the last three years along with explanations.
The federal contract opportunity is solicitation number 36C77622B0018 for infrastructure upgrades to allow for a new Electronic Health Record Modernization system at the Iron Mountain VA medical center. The scope of work includes electrical upgrades, bonding, UPS installation, building management system interfaces, HVAC renovations and expansions, communication infrastructure upgrades including new data outlets and fiber backbone upgrades campus wide, and physical security upgrades. The contracting agency is the Department of Veterans Affairs Technology Acquisition Center located in Austin.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77622B0018 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 .