Attachment 19 - Contractor Safety and Environmental Record Evaluation Form.docx
DOCX document 14 KB Posted
- Attached to
- Y1LZ--650-348 Construction of Valley Street Parking Lot Improvements Minor Construction- Providence, RI
- Solicitation number
- 36C77624R0040
About this file
This document contains a contractor safety and environmental record evaluation form and details of a related federal contract opportunity for construction work. The evaluation form requests a company's OSHA 300 form information for the past four years, including man hours, cases involving days away from work or restricted activity, and DART rates. It also asks for any serious, willful, or repeat OSHA violations in the past three years along with explanations.
The federal contract opportunity is solicitation number 36C77624R0040 for construction of parking lot improvements at the Valley Street Parking Lot in Providence, Rhode Island. The contracting agency is the Department of Veterans Affairs Technology Acquisition Center located in Austin. No further details are provided regarding required products or services, response dates, pricing terms, or other salient information.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77624R0040 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 .