Attachment 9 - Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C77623B0065
About this file
This is a contractor safety and environmental record evaluation form related to solicitation 36C77623B0065 for EHRM training and administrative support services for the Department of Veterans Affairs Technology Acquisition Center Austin. The form requests contact information and OSHA 300 data from contractors including total man hours, cases involving days away from work or job transfer, days away from work rate, and any serious, willful, or repeat OSHA violations over the past three years along with explanations. Review of this safety record information will be part of the source selection process for the solicitation.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0065 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________ Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2018 |
| 2019 |
| 2020 |
| 2021 |
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 .