Attachment IV - Contractor EMR Certification Form 610-19-103.pdf
PDF 138 KB Posted
- Solicitation number
- 36C25023B0075
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity for remodeling the first floor of Building 138 at a Veterans Affairs medical center. The evaluation form requests a contractor's OSHA 300 and 300A forms from 2019 to 2022, North American Industry Classification System code, details on the company's safety and health program administrator, and experience modification rate. The related federal contract opportunity is solicitation number 36C25023B0075 for Z2DZ--Remodel 1st Floor, Bldg. 138 610-19-103 with drawing and specifications from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10. Contractors are required to submit the completed safety evaluation form to be considered for this remodeling project at a Veterans Affairs medical facility.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Attachment D-1.pdf | ||
| Attachment E.pdf | ||
| Attachment F.pdf | ||
| Attachment D.pdf | ||
| 36C25023B0075 0005.pdf | ||
| 36C25023B0075 0004.pdf | ||
| Attachment C.pdf | ||
| 36C25023B0075 0003.pdf | ||
| 36C25023B0075 0001 (Correction).pdf | ||
| Attachment B.pdf | ||
| Attachment A.pdf | ||
| 36C25023B0075 0002.pdf | ||
| Attachment - Attendance Sheet.pdf | ||
| 36C25023B0075 0001.pdf | ||
| 36C25023B0075-1.pdf | ||
| 36C25023B0075_2.docx | DOCX document | |
| 36C25023B0075.pdf | ||
| Attachment III - Wage Determination (DBA).pdf | ||
| Attachment VI - VHA_Directive_1192.pdf | ||
| Attachment V - RFI Form-36C25023B0075.pdf | ||
| Attachment II - Specs.pdf | ||
| Attachment I - Drawings.pdf | ||
| 36C25023B0075_1.docx | DOCX document |
Show all 23
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 Project 610-19-103:
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. 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.
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: 238210
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 .