Attachment 18 - Contractor Safety - Environmental Form.docx

14 KB Posted

Attached to
Y1DA--626-309 Construct Integrated Health Center (Minor) - Murfreesboro
Solicitation number
36C77623B0037
Issued by

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This document contains a contractor safety and environmental record evaluation form and details of a related federal contract opportunity. The evaluation form requests information on a contractor's man hours, OSHA recordable incidents, days away from work rate, and any serious OSHA violations over the past four years.

The related federal contract opportunity is solicitation number 36C77623B0037 to construct an integrated health center in Murfreesboro, Tennessee for the Department of Veterans Affairs Technology Acquisition Center Austin. No further details are provided on the required scope of work, response deadline, period of performance, or place of performance.

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Contractor Safety and Environmental Record Evaluation Form

Information provide below is current and applicable to Solicitation 36C77623B0037 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 .