S02 - ATTACHMENT 19 - Contractor Safety - Environmental Form.pdf
PDF 117 KB Posted
- Attached to
- EHRM Infrastructure Upgrades West Campus – North Chicago - Construction Federal contract opportunity
- Solicitation number
- 36C77623B0019
About this file
This document contains a Contractor Safety and Environmental Record Evaluation Form and details of a related federal contract opportunity. The form requests safety and environmental record information from contractors, including man-hours, OSHA cases, DART rates, and any serious violations over the past three years.
The related federal contract opportunity is solicitation number 36C77623B0019 for EHRM Infrastructure Upgrades West Campus - North Chicago Construction from the Department of Veterans Affairs Technology Acquisition Center Austin. The description provided is for construction services to upgrade infrastructure at the West Campus facility in North Chicago. No further details are included regarding response dates, pricing terms, set asides, or incumbent contractors.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623B0019
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.
Contractor Safety and Environmental Record Evaluation Form
File details come from the government source that posted it. Updated .