Attachment 7 - EMR.docx
DOCX document 14 KB Posted
- Attached to
- Z1DA--Replace Damaged Flooring 539-23-202
- Solicitation number
- 36C25024B0019
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and details of a federal contract opportunity for replacing damaged flooring at a Veterans Affairs medical center. The evaluation form requests a contractor's OSHA 300 forms from the past three years detailing man hours, cases involving days away from work, restricted activity rates, and any serious OSHA violations. It also asks for the contractor's NAICS code and information on its safety program administrator and insurance experience modification rate. The federal contract opportunity is for solicitation number 36C25024B0019 to replace carpet and flooring throughout a hospital damaged by water and mold. The work includes general construction, electrical, technology, and possible abatement. All phases of the project must be completed within 90 days of a notice to proceed. The awarding agency is the Department of Veterans Affairs Veterans Health Administration VISN 10.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25024B0019 0002.docx | DOCX document | |
| 36C25024B0019 0001.docx | DOCX document | |
| 36C25024B0019_1.docx | DOCX document | |
| Attachment 1 - Replace Damaged Flooring - Drawings.pdf | ||
| Attachment 2 - Replace Damaged Flooring - Project Manual Specs.pdf | ||
| 36C25024B0019_1.pdf | ||
| WD.txt | TXT text file | |
| Attachment 3 - VAAR 852.219-75 VA Notice of Limitations on Subcontracting (JAN 2023).pdf | ||
| Attachment 4 - VHA_Directive_1192.pdf | ||
| Attachment 5 - RFI Form-36C25023B0034.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 # 36C25023B0063.
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2022 |
| 2021 |
| 2020 |
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 .