Attachment 21 - Contractor Safety and Environmental Form.docx
DOCX document 14 KB Posted
- Attached to
- Y1DA--578-21-706 EHRM Training and Admin Space Support - Phase 2 - Hines, IL (VA-22-00052631)
- Solicitation number
- 36C77622B0050
About this file
This document contains a contractor safety and environmental record evaluation form and details of a related federal contract opportunity. The evaluation form requests a contractor to provide health and safety performance metrics from their OSHA 300 forms for the past four years, including total man hours, number of injury cases requiring days away from work, restricted duty or job transfer, and their days away from work restricted or transferred rate. It also asks for any serious, willful or repeat OSHA violations in the last three years along with an explanation.
The related federal contract opportunity is solicitation number 36C77622B0050 for EHRM training and administrative space support services at the Hines, Illinois VA facility. The opportunity type is a solicitation and the requesting agency is the Department of Veterans Affairs Technology Acquisition Center located in Austin. No further details are provided on required products or services, response dates, 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 36C77622B0050 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 .