ATTACHMENT 6 - Contractor Safety - Environmental Record Evaluation Form.docx

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Attached to
Z2DA--Renovate Oncology Hematology, for 1st Floor Bldg. 1 - Wichita
Solicitation number
36E77620B0005
Issued by

About this file

This solicitation notice provides details for a renovation construction project at the Robert J. Dole VA Medical Center in Wichita, Kansas. The Department of Veterans Affairs seeks to award a firm-fixed-price contract through a competitive solicitation process to a Service-Disabled Veteran-Owned Small Business for renovations and relocation of the oncology, hematology, and dialysis departments on the first floor. The renovation work includes general construction, alterations, roads, walks, grading, drainage and necessary removal of existing structures. The period of performance is approximately 270 calendar days with the solicitation to be issued in mid to late June 2020 and magnitude of construction is estimated between $2,000,000 to $5,000,000. Questions must be submitted in writing by the specified deadline.

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Contractor Safety and Environmental Record Evaluation Form

Information provide below is current and applicable to Solicitation 36E77620B0001 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:

Category
2016
2017
2018
2019

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 .