Contractor Safety - Environmental Form.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C77622B0023_1
About this file
This form requests safety and environmental records from contractors. It asks for company information and OSHA record details 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 over the past three years along with explanations. The related federal contract opportunity is to expand the emergency department at the Lake Nona VA Medical Center in Orlando, Florida. Solicitation number 36C77622B0023_1 requests bids for minor construction work. The contracting agency is the Department of Veterans Affairs Technology Acquisition Center in Austin, Texas.
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Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77622B0023 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 .