S02 - Attachment 05 - Contractor Safety - Environmental Form.docx
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- Attached to
- 36C77623B0062 - EHRM Infrastructure Data Center Upgrades - Dublin, GA -Solicitation Federal contract opportunity
- Solicitation number
- 36C77623B0062
About this file
This document contains a contractor safety and environmental record evaluation form and information about a related federal contract opportunity. The evaluation form requests information from contractors such as company name, address, contact details, total man hours for 2019 through 2022, OSHA recordable incidents, days away from work rates, and details on any OSHA violations from the past three years.
The related federal solicitation is numbered 36C77623B0062 and is for EHRM infrastructure data center upgrades at the Dublin, GA Department of Veterans Affairs facility. The solicitation is being conducted by the Department of Veterans Affairs Technology Acquisition Center Austin. No further details are provided on the required products or services, response deadline, or award timing.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0062 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 .