Attachment 7 - EMR.docx
DOCX document 14 KB Posted
- Attached to
- Z1DA--SWITCH GEAR ROOM COOLING 583-24-505
- Solicitation number
- 36C25024B0020_1
About this file
This document contains a pre-award contractor safety evaluation form and information on a related federal contract opportunity for switchgear room cooling system installation.
The evaluation form requests a contractor's OSHA 300 forms from the past three years listing man hours, days away from work cases, daily rate of injuries, and serious violations. It also asks for the contractor's NAICS code, safety program administrator, and experience modification rate. The federal contract opportunity is solicitation number 36C25024B0020_1 from the Department of Veterans Affairs to furnish and install a 15-ton packaged air conditioning system in an electrical switchgear room. The project includes exhaust fan removal, concrete work, equipment installation, ductwork, and building management system integration. Completion of the cooling system installation will ensure proper operation of critical high voltage electrical components.
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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 .