Attachment 8 - Contractor Safety - Environmental Form.docx
DOCX document 27 KB Posted
- Attached to
- EHRM Birmingham Infrastructure Upgrades Federal contract opportunity
- Solicitation number
- 36C77623B0026
About this file
This document contains a contractor safety and environmental record evaluation form and information on a related federal contract opportunity for infrastructure upgrades. The form requests contact information and safety data from a company's OSHA 300 forms for the last four years, including man hours, cases involving days away from work or restricted activity, days away/restricted/transferred rate, and any serious, willful, or repeat OSHA violations along with explanations. The related federal contract opportunity is solicitation number 36C77623B0026 from the Department of Veterans Affairs Technology Acquisition Center Austin. It seeks to provide all labor, materials, management and services necessary to complete electronic health records modernization infrastructure upgrades at the Veterans Affairs Medical Center in Birmingham, Alabama.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C77623B0026. Please include this completed form in your bid or proposal.
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.
ATTACHMENT #4 TO SOLICITATION 36C77623B0026 - EHRM BIRMINGHAM INFRASTRUCTURE UPGRADES
File details come from the government source that posted it. Updated .