Attachment 3 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Attached to
- C1AA--459-21-2-880-0014 EHRM (VA-21-00029828)
- Solicitation number
- 36C77621R0149
About this file
This document contains a contractor safety and environmental record evaluation form and details of a federal contract opportunity for design-build services. The evaluation form requests a contractor's OSHA 300 forms and related safety data from 2017 to 2020, including man hours, days away from work cases, restricted activity cases, and serious violations. The federal contract opportunity is a solicitation from the Department of Veterans Affairs for design and construction services to upgrade telecommunications rooms and a data center at the VA Pacific Islands Health Care System in accordance with EHRM infrastructure standards. The solicitation will be a service-disabled veteran-owned small business set aside and issued in July 2021 as a request for proposal, with a performance period of approximately 540 calendar days from notice to proceed. The magnitude of construction is estimated between $10 million to $20 million.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77621R0149 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2017 |
| 2018 |
| 2019 |
| 2020 |
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 .