Attachment 4 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Attached to
- Y1DA--583-21-701 EHRM Infrastructure Construction Indianapolis Federal contract opportunity
- Solicitation number
- 36C77623B0056
About this file
This document contains a contractor safety and environmental record evaluation form for federal solicitation number 36C77623B0056 for EHRM infrastructure construction services in Indianapolis for the Department of Veterans Affairs Technology Acquisition Center Austin. The form requests the contractor's company information and OSHA 300 data for the last four years 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 along with explanations for any violations.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C77623B0056 0003.docx | DOCX document | |
| S04 - Site Visit Sign in Sheet.pdf | ||
| Data Port and Cable Tray Survey Data.pdf | ||
| 36C77623B0056 0002.docx | DOCX document | |
| Attachment 2 - (3 of 3).zip | ZIP file | |
| Attachment 2 - (1 of 3).zip | ZIP file | |
| Attachment 2 - (2 of 3).zip | ZIP file | |
| 36C77623B0056 0001.docx | DOCX document | |
| Attachment 6 - 852.219-75 Clause for EAS.docx | DOCX document | |
| Attachment 5 - DBA Wage Rate Marion County - 8-11-23.pdf | ||
| Attachment 2 - Drawings.zip | ZIP file | |
| 36C77623B0056_1.docx | DOCX document | |
| Attachment 3 - Site Visit Memo EHRM Infrasctrure Upgrade.docx | DOCX document | |
| Attachment 1 - Specifications and attachments.zip | ZIP file |
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0056 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 .