Attachment 19 - Contractor Safety and Environmental Record Evaluation Form.docx

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Attached to
Y1AZ--674A4-21-703 EHRM Training and Admin Support Space Construction Waco Texas (VA-22-00050768)
Solicitation number
36C77622B0045
Issued by

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This document contains a Contractor Safety and Environmental Record Evaluation Form to be completed by bidders for Solicitation 36C77622Q0327. The form requests information on man hours, OSHA recordable incidents, DART rates, and any serious, willful, or repeat OSHA violations over the past four years. Bidders must attach an explanation for any OSHA violations.

The related federal contract opportunity is Solicitation 36C77622B0045 for EHRM Training and Admin Support Space Construction at the Waco, Texas VA facility. The solicitation is for construction services issued by the Department of Veterans Affairs Headquarters. Safety and environmental performance as demonstrated on the attached evaluation form will likely be an evaluation criterion for award.

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Contractor Safety and Environmental Record Evaluation Form

Information provide below is current and applicable to Solicitation 36C77622Q0327 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 .