Attachment 36 - Contractor Safety - Environmental Form.docx
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- Attached to
- 36C77623B0043 - EHRM Infrastructure Upgrades - Hines, IL - Solicitation Federal contract opportunity
- Solicitation number
- 36C77623B0043
About this file
This is a contractor safety and environmental record evaluation form for solicitation 36C77623B0043 from the Department of Veterans Affairs Technology Acquisition Center Austin. The form requests a company's name, address, phone number, email, contact information, and OSHA 300 form data from 2019 through 2022 including man hours, cases involving days away from work or restricted activity, days away restricted or transferred rate, and any serious, willful, or repeat OSHA violations from the last three years along with an explanation for any violations. The related solicitation is for EHRM infrastructure upgrades at Hines, Illinois and is identified as a special notice opportunity.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0043 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 .