Attachment III - Contractor EMR Certification Form 610-21-213.docx
DOCX document 17 KB Posted
- Attached to
- Z1DA--Install Landscaping 610-21-213 --Q&A Federal contract opportunity
- Solicitation number
- 36C25022B0033
About this file
This document includes a pre-award contractor safety and environmental record evaluation form and details of a federal contract opportunity for landscaping services. The evaluation form requests information on the contractor's safety record including OSHA 300 and 300a forms, North American Industry Classification code, safety program administration, and experience modification rate. The related federal contract opportunity is for landscaping work at multiple locations on the VA Northern Indiana Health Care Marion Campus requiring removal of existing landscaping and its replacement within 84 calendar days. The justification provided is for campus-wide landscaping improvements.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25022B0033 0004_1.docx | DOCX document | |
| Attachment - Sign in Sheet.pdf | ||
| 36C25022B0033 0003.docx | DOCX document | |
| 36C25022B0033 0002.docx | DOCX document | |
| 36C25022B0033 0001_1.docx | DOCX document | |
| Attachment VI - VHA Directive 1192.01.pdf | ||
| Attachment I - COMBINED SPECS.pdf | ||
| 36C25022B0033_2.docx | DOCX document | |
| Attachment II - DRAWINGS.pdf | ||
| Attachment V - DBA -Wage_Determination.pdf | ||
| 36C25022B0033 (1).pdf | ||
| Attachment IV - RFI Form.docx | DOCX document | |
| 36C25022B0033_1.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 Project 610-21-213:
Company Name: Address: Telephone: Fax: Email: Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2018 |
| 2019 |
| 2020 |
| 2021 |
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: 236220
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. Updated .