Attachment 6 Contractor Safety and Environmental Record Evaluation Form.docx
DOCX document 17 KB Posted
- Attached to
- Z1DA--603-24-902 Asbestos Abatement
- Solicitation number
- 36C24924R0023
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for a solicitation seeking asbestos abatement services. The solicitation is numbered 36C24924R0023 and is being conducted by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The evaluation form requests contact information for the bidding company and details of its safety record over the past three years, including total man hours, OSHA-reportable incidents, days away from work or job transfer rates, and any serious, willful, or repeat OSHA violations. It also asks for the company's NAICS code, who administers its safety program, and its insurance experience modification rate. Copies of the company's past three years of OSHA Forms 300 and 300A are to be attached.
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Other files
| File | Type | Posted |
|---|---|---|
| Site Visit Sign In Sheet dated 12152023.pdf | ||
| Solicitation Notice 36C24924R0023 0001.pdf | ||
| Attachment 3 WD Jefferson County Building KY20230093 dated 08182023.pdf | ||
| Attachment 2 Drawing 603-24-902A 8W.pdf | ||
| Attachment 5 Construction Past Performance Questionnaire.docx | DOCX document | |
| Attachment 7 Calculation of Contractor Self Performed Work.xlsx | XLSX spreadsheet | |
| 36C24924R0023_1.docx | DOCX document | |
| Attachment 4 Construction Pricing Schedule.xlsx | XLSX spreadsheet | |
| Attachment 1 Drawing 603-24-901A 9S.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 36C24924R0023
Company Name:
Address:
Telephone:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 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.
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: 562910 – Remediation Services
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate (EMR):
END OF ENVIRONMENTAL RECORD EVALUATION
File details come from the government source that posted it. Updated .