S02 Contractor EMR Certification Form 2021_515-21-108.pdf
PDF 163 KB Posted
- Solicitation number
- 36C25022B0069
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for the solicitation 36C25022B0069 to waterproof various building basements at facilities of the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10. The form requests company identifying information and safety data from OSHA 300 forms for the last three years, including man hours, days away from work cases, restricted activity cases, and serious violations. It also requests the company's NAICS code and information on its safety program administrator and insurance experience modification rate. Attached OSHA 300 and 300a forms from the last three years are required.
View the file
Other files
Show all 18
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C25022B0069 Company Name: ______________________________________________ Address:
_____________________________________________________ Telephone:
______________________ Fax: ________________________ Email: _______________________________________________________ Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 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: __________________________________
3. Who administers your company’s Safety and Health Program? _____________________
4. Company’s Insurance Experience Modification Rate (EMR): ______________________ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .