36C25018B0823-018.docx
DOCX document 14 KB Posted
- Attached to
- Replace Windows-Various Buildings 515-14-103 Federal contract opportunity
- Solicitation number
- 36C25018B0823
About this file
36C25018B0823 S02 - Contractor EMR Certification Form 2018 - 515-14-103.docx
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| 36C25018B0823-0001001.pdf | ||
| 36C25018B0823-0001000.docx | DOCX document | |
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| 36C25018B0823-001.docx | DOCX document | |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C250
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2016 |
| 2017 |
| 2018 |
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.
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. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program? ____________________________.
4. Company’s Insurance Experience Modification Rate (EMR): ____________________________
File details come from the government source that posted it.