ATTACHMENT 25 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Attached to
- Y1AZ--EHRM Infrastructure Upgrades Construction West Palm Beach Federal contract opportunity
- Solicitation number
- 36C77623B0045
About this file
This is a contractor safety and environmental record evaluation form related to solicitation number 36C77623B0045 for Y1AZ--EHRM Infrastructure Upgrades Construction at the West Palm Beach Department of Veterans Affairs facility. The form requests a contractor's OSHA 300 data from 2019 through 2022 including total man hours, number of cases involving days away from work or job transfer, days away from work rate, and any serious, willful, or repeat OSHA violations from the past three years along with explanations. The solicitation is for construction services and the completed form will be evaluated as part of the contractor safety and environmental record.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0045 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 .