Attachment T- Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C77621R0156
About this file
This document contains a contractor safety and environmental record evaluation form and information on a federal contract solicitation. The evaluation form requests information from contractors such as number of man hours, OSHA recordable incidents, days away from work rates, and any serious OSHA violations over the past three years.
The related federal contract solicitation is to design and construct a multi-level precast concrete parking structure of approximately 350,000 square feet and 5-levels at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin. The parking structure is intended to accommodate approximately 900-1000 new parking spaces. Additional requirements include a new three bay truck dock facility and central storage/warehousing space. The solicitation will be issued as a request for proposal to a service-disabled veteran-owned small business set-aside with a response deadline in late November 2021 and an anticipated period of performance of 485 calendar days.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77621R0156 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 .