Attachment 8 - Contractor Safety - Environmental Form.docx

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Attached to
36C77623B0063 - EHRM Infrastructure System Upgrades, Chicago, IL - Solicitation Federal contract opportunity
Solicitation number
36C77623B0063
Issued by
Department of Veterans Affairs Technology Acquisition Center Austin

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This is a contractor safety and environmental record evaluation form for solicitation 36C77623B0063 from the Department of Veterans Affairs Technology Acquisition Center Austin. The form requests contact information and OSHA 300 data from 2019 to 2022 including 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 from the last three years along with explanations. The related solicitation is for EHRM infrastructure system upgrades in Chicago, Illinois.

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Attachment 1 - E. EHRM Infrastructure Upgrades Specifications.pdf PDF
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Attachment 6 - E. EHRM Infrastructure Addendum 1 - Part 2 of 2.pdf PDF
Attachment 3 - E. EHRM Infrastructure Upgrades Part 2 of 3.pdf PDF
Attachment 2 - E. EHRM Infrastructure Upgrades Part 1 of 3.pdf PDF
Attachment 4 - E. EHRM Infrastructure Upgrades Part 3 of 3.pdf PDF
Attachment 5 - E. EHRM Infrastructure Addendum 1 - Part 1 of 2.pdf PDF
Attachment 7 - Wage Rates.pdf PDF
Attachment 10 - SECNAV_5512_2024 fillable (site visit).pdf PDF
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Contractor Safety and Environmental Record Evaluation Form

Information provide below is current and applicable to Solicitation 36C77623B0063 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 .