ATTACHMENT 7 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C77623B0039
About this file
This document contains a contractor safety and environmental record evaluation form and information on a related federal contract opportunity. The evaluation form requests company information and safety data from the past four years, including total man-hours, OSHA recordable incidents, days away from work rates, and any serious violations. The related solicitation is for minor construction services at a VA facility in Tucson, Arizona, issued by the VA Technology Acquisition Center with number 36C77623B0039. Responses are due based on the listed solicitation number and issue date. The opportunity is for acquiring parking lot construction services at a VA medical center located in Tucson.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0039 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 .