Attachment 18 - Contractor Safety - Environmental Form.docx
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- Attached to
- 36C77623B0011 - Solicitation - EHRM Infrastructure Upgrades - Madison, WI Federal contract opportunity
- Solicitation number
- 36C77623B0011
About this file
This document includes a contractor safety and environmental record evaluation form and solicitation for the EHRM Infrastructure Upgrades project at the Madison VA Medical Center.
The contractor safety and environmental record evaluation form requests contact information and safety data from the past four years, including total man hours, OSHA recordable incidents, days away from work rates, and any serious violations. Bidders must attach explanations for any OSHA violations within the last three years.
The solicitation seeks a single firm-fixed-price contract to furnish all labor, materials, equipment and supervision for the EHRM Infrastructure Upgrades project. This includes replacing all telecommunications cable, outlets and associated equipment for multiple buildings on the Madison VA campus. The Department of Veterans Affairs Technology Acquisition Center Austin will award the contract consistent with the provided drawings and specifications. Bids are due by the date specified in the solicitation.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0011 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2019 |
| 2020 |
| 2021 |
| 2022 |
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 .