ATTACHMENT 7 - CONTRACTOR SAFETY AND ENVIRONMENTAL RECORD FORM.docx

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Attached to
Y1AB--657A5-21-702 EHRM Training and Admin Space Support Construction - Marion, IL VAMC Federal contract opportunity
Solicitation number
36C77623B0060
Issued by
Department of Veterans Affairs Technology Acquisition Center Austin

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This document is a contractor safety and environmental record evaluation form for solicitation 36C77623B0060 for EHRM training and administrative space support construction services at the Marion, Illinois VA Medical Center. The form requests contractors provide their OSHA 300 forms from 2019 through 2022 detailing man hours, cases involving days away from work or restricted activity, days away restricted or transferred rate, and any serious, willful, or repeat OSHA violations over the past three years along with explanations. The solicitation is for the Department of Veterans Affairs Technology Acquisition Center in Austin, Texas.

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Contractor Safety and Environmental Record Evaluation Form

Information provide below is current and applicable to Solicitation 36C77623B0060 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 .