ATTACHMENT 19 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C77621B0009
About this file
This form requests safety and environmental records from contractors for a solicitation to expand and renovate a building for urgent and primary care at the Tomah VA Medical Center. Contractors must provide their company name, address, phone number, email, contact information, and OSHA 300 form data for the last four years including total man hours, cases involving days away from work or job transfer, DART rates, and any serious, willful, or repeat OSHA violations along with explanations. The solicitation number is 36C77621B0009 and the work includes demolition, site preparation, and furnishing labor and materials to complete the building expansion and renovation per attached drawings and specifications. The contracting agency is the Department of Veterans Affairs Technology Acquisition Center located in Austin.
View the file
Other files
Show all 29
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77621B0009 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2018 |
| 2019 |
| 2020 |
| 2021 |
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 .