Attachment 23 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C77623B0066
About this file
This is a contractor safety and environmental record evaluation form for solicitation 36C77623B0066 for infrastructure upgrades construction at the Kansas City VA Medical Center. The form requests a company's name, address, phone, fax, email and contact information. It asks for man hours, OSHA injury cases, days away from work rate, and any serious, willful or repeat OSHA violations over the past four years. The related solicitation is for the Y1DA-EHRM Infrastructure Upgrades Construction project in Kansas City, Missouri being conducted by the Department of Veterans Affairs Technology Acquisition Center in Austin.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0066 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 .