Attachment 3 - Safety and Environmental Record Evaluation Form.pdf
PDF 111 KB Posted
- Solicitation number
- 36C25021B0002
About this file
This document includes a pre-award contractor safety and environmental record evaluation form and details of a federal contract opportunity for parking garage restoration work. The evaluation form requests safety-related information including company name and address, contact details, NAICS code, insurance experience modification rate, and OSHA 300 forms from 2017 to 2019 with metrics on man-hours, injuries, and violation details. The federal contract opportunity is solicitation number 36C25021B0002 from the Department of Veterans Affairs for parking garage restoration work at the Cincinnati VA Medical Center with an estimated value between $250,000 and $500,000. The IFB is to be posted on or around November 20th, 2020 with a bid opening within 30-45 days and a 210-day performance period from notice to proceed. The specification and drawings will be available with the IFB. Requests for IFBs should be submitted before November 19th, 2020. This is a total small business set-aside.
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Other files
| File | Type | Posted |
|---|---|---|
| RFI - Replys.pdf | ||
| 36C25021B0002 0001.docx | DOCX document | |
| Attachment 1 - Drawings - 2020_0826.pdf | ||
| Attachment 5 - DBA - OH20200082.pdf | ||
| 36C25021B0002_1.docx | DOCX document | |
| Attachment 4 - Request for Information Form.pdf | ||
| Attachment 2 - Specifications - 2020_0826.pdf |
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Text version
Pre-Award Contractor Safety and Environmental Record
Evaluation Form Information provided below is current and applicable to Solicitation # 36C25021B0002.
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2017 2018 2019
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.
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page:
http://www.osha.gov/pls/publications/publication.html.
2. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate (EMR):
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .