Attachment 5 CONTRACTOR SAFETY AND ENVIRONMENTAL RECORD EVALUATION FORM.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C77622B0024
About this file
This document contains a Contractor Safety and Environmental Record Evaluation Form for a solicitation to renovate the nuclear medicine department at the Chicago VA Medical Center. The form requests contractors to provide man-hours and OSHA recordable incident details from 2017 to 2020, including number of cases involving days away from work and restricted duty, days away from work rate, and any serious, willful, or repeat OSHA violations in the last three years along with explanations. The solicitation number is 36C77622B0024 for project Y1DA-537-325 to renovate nuclear medicine at the Chicago VA Medical Center, issued by the Department of Veterans Affairs Headquarters. Contractors are required to submit this safety record form to be evaluated for the renovation project.
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| Attachment 1- Chicago S05 - Technical Questions Tracking Spreadsheet.docx | DOCX document | |
| Attachment 4- IFB Microsoft Teams Meeting Information Chicago.docx | DOCX document | |
| 36C77622B0024 0002.docx | DOCX document | |
| 36C77622B0024 0001.docx | DOCX document | |
| Attachment Nuclear Med site visit.pdf | ||
| Attachment 3 Zip 4 Drawings.zip | ZIP file | |
| Attachment 4 Wage Determination 4.27.22.pdf | ||
| Attachment 3 Zip 1 Drawings.zip | ZIP file | |
| Attachment 6 Site Visit Instructions .pdf | ||
| Attachment 1 SOW.docx | DOCX document | |
| 36C77622B0024_1.docx | DOCX document | |
| Attachment 2 Nuclear Med Specs.zip | ZIP file | |
| Attachment 3 Zip 2 Drawings.zip | ZIP file | |
| Attachment 3 Zip 3 Drawings.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 36C77622B0005 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 .