Attachment IV - EMR Attachment.docx
DOCX document 14 KB Posted
- Attached to
- Y1DZ--CON - Build Sim Lab 610A4-21-201
- Solicitation number
- 36C25024B0006
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and details of a related federal contract opportunity for construction services. The evaluation form requests contact information and safety data including total man hours, OSHA recordable incidents, days away from work, and serious violations over the past three years. It also asks for the company's NAICS code and information on its safety program administration and experience modification rate. The related federal contract opportunity is for building a simulation lab at a Veterans Affairs medical center, issued by the VA Veterans Health Administration. It provides the solicitation number and opportunity type as a pre-solicitation notice.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form Information provided below is current and applicable to Solicitation 36C2524B0006 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 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: __________________________________ |
| 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 .