Attachment VII - EMR Form.docx
DOCX document 14 KB Posted
- Attached to
- Z2DA--CON Add Card Readers - 610A4-21-202
- Solicitation number
- 36C25024B0022
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for the Department of Veterans Affairs solicitation numbered 36C25024B0022 to add card readers at Veterans Integrated Service Network 10 facilities. The form requests contact information and safety data including total man hours, OSHA recordable incidents, days away from work rates, and serious violations over the past three years. It also asks for the company's North American Industry Classification System code and details on its safety program administrator and insurance experience modification rate.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form Information provided below is current and applicable to Solicitation 36C25024B0022:
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 .