Attachment 4 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C77622B0058
About this file
This form requests contractor safety and environmental record information to be submitted in response to solicitation number 36C77622B0058 for the renovation of an EHRM training room in Topeka, Kansas for the Department of Veterans Affairs Technology Acquisition Center Austin. The form requests the contractor's company information and OSHA 300 data including total man hours, 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 for any violations.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77622B0058 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.
File details come from the government source that posted it. Updated .