EMR 1 page.pdf
PDF 228 KB Posted
- Attached to
- Z2DA--FY26: NRM (PROJ: 516-CSI-142) BB - Site Prep for Emergency Department CT Scanner Replacement
- Solicitation number
- 36C24826Q0004
About this file
The document is a Pre-Award Contractor Safety and Environmental Record Form, which requires potential contractors to provide detailed safety and workplace injury information. The form requests three years of data (2022-2024) on man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rate, and any serious, willful, or repeat violations from OSHA or EPA. Companies must also attach OSHA 300 and 300a Forms, identify who administers their Safety and Health Program, and provide their Insurance Experience Modification Rate (EMR), which must be 1 or less to meet requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24826Q0004 0005.pdf | ||
| WD-FL20260222 01-02-26.pdf | ||
| Guldmann_GH3_BayPines_VA_Submission_Package.pdf | ||
| 36C24826Q0004 0004.pdf | ||
| Base Offer Price Breakdown - 1 page.xlsx | XLSX spreadsheet | |
| 36C24826Q0004 0003.docx | DOCX document | |
| 516-CSI-142 - Bay Pines ED CT_ADD 1.pdf | ||
| 03 30 00-CAST-IN-PLACE CONCRETE.pdf | ||
| 01 45 29-TESTING LABORATORY SERVICES.pdf | ||
| 36C24826Q0004 0002.docx | DOCX document | |
| RFI_516-CSI-142 Pre-Bid.docx | DOCX document | |
| PAST AND PRESENT PERFORMANCE QUESTIONNAIRE.docx | DOCX document | |
| ED CT scanner site walk sign-in sheet 10-07-25.pdf | ||
| 36C24826Q0004 0001.docx | DOCX document | |
| 516-CSI-142_Bay Pines_ED CT_ Specs.pdf | ||
| VHA Infection Control Risk Assessment.pdf | ||
| 36C24826Q0004_1.docx | DOCX document | |
| WD-FL20250222 05-23-2025.pdf | ||
| 516-CSI-142_Bay Pines_ED CT_ Drawings.pdf |
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Attachment
Safety or Environmental Violations and Experience Modification Rate
Pre-Award Contractor Safety and Environmental Record Form
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2022 2023 2024
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 or any EPA violations within the last 3 years. Please attach explanation for any violations.
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page:
http://www.osha.gov/pls/publications/publication.html.
2. Who administers your company’s Safety and Health Program?
3. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of 1 or less is required): _____________ http://www.osha.gov/pls/publications/publication.html
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
File details come from the government source that posted it. Updated .