S02 - ATTACHMENT 24 - Contractor Safety - Environmental Form.pdf
PDF 117 KB Posted
- Attached to
- EHRM Infrastructure Upgrades Construction - Central Western Massachusetts Federal contract opportunity
- Solicitation number
- 36C77623R0051
About this file
This document is a contractor safety and environmental record evaluation form and related federal contract opportunity solicitation. The form requests safety and environmental record information from 2019 to the present, including man hours, OSHA recordable incidents, days away from work rates, and serious violations. Companies must provide explanations for any violations.
The related federal contract opportunity is solicitation number 36C77623R0051 for EHRM infrastructure upgrades construction projects in central western Massachusetts from the Department of Veterans Affairs Technology Acquisition Center Austin. No further details are provided on the scope of work, response deadline, or award date.
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Text version
Contractor Safety and Environmental Record Evaluation Form
Information provide below is current and applicable to Solicitation 36C77623R0051
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 .