Attachment 18 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Attached to
- 36C77622B0029 - Replace Boilers - Leavenworth - Solicitation Federal contract opportunity
- Solicitation number
- 36C77622B0029
About this file
This document includes a contractor safety and environmental record evaluation form and details of a federal solicitation for replacing boilers at a Department of Veterans Affairs medical center.
The evaluation form requests a contractor's OSHA 300 Form information over multiple years including man hours, cases involving days away from work or restricted activity, days away restricted or transferred rate, and any serious, willful or repeat OSHA violations in the last three years.
The solicitation seeks bids to award a firm-fixed-price contract for replacing four antiquated water tube boilers and associated piping and support systems with three new energy efficient fire tube boilers at the Dwight D. Eisenhower VA Medical Center in Leavenworth, Kansas. The project scope also includes replacing auxiliary systems in one building, fuel oil pump sets, condensate piping, a deaerator tank, condensate return tank, adding a continuous blowdown heat recovery package, and asbestos abatement of replaced piping. The solicitation was issued by the Department of Veterans Affairs Technology Acquisition Center Austin.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77621B0013 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 .