ATTACHMENT 23 - Contractor Safety - Environmental Form.pdf
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- Solicitation number
- 36C77623B0005
About this file
This form requests safety and environmental records from contractors for the EHRM Infrastructure Upgrades at the Cincinnati VAMC project. The Department of Veterans Affairs Technology Acquisition Center Austin is soliciting bids for construction services under solicitation number 36C77623B0005. Contractors should provide their company name, address, phone number, email, and point of contact. Utilizing OSHA 300 forms, contractors must disclose their number of man hours, cases involving days away from work or restricted activity, DART rates, and any serious, willful, or repeat OSHA violations over the past three years along with explanations for any violations. Relevant safety records are requested to evaluate contractors for this infrastructure construction project at the Cincinnati VAMC.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0005
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.
Contractor Safety and Environmental Record Evaluation Form
File details come from the government source that posted it. Updated .