Attachment VI - EMR Form.pdf
PDF 134 KB Posted
- Attached to
- Z2DA--Replace Outbuilding Gutters 610A4-24-504 Federal contract opportunity
- Solicitation number
- 36C25024B0029
About this file
This solicitation requests proposals to replace gutters on outbuildings at the VA Northern Indiana Health Care System campus in Fort Wayne, Indiana. The scope of work involves removing existing gutters and installing new matching gutter systems on eight outbuildings between the hours of 0700 and 1600 on Saturdays and Sundays only. Proposals are due within 60 days of notice to proceed, and the selected contractor must provide a warranty to cover materials, workmanship, and repairs for leaks not caused by the VA within 72 hours of notification for the warranty period. Safety requirements specify that a 30-hour OSHA Competent Person and trade certifications are required for all contractor personnel.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25024B0029 0002.pdf | ||
| Attachment A - pre-bid sign in sheet.pdf | ||
| 36C25024B0029 0001.pdf | ||
| Attachment II - Annex A.pdf | ||
| Attachment I - Standards.pdf | ||
| 36C25024B0029.pdf | ||
| Attachment IV - DBA-IN20230002.pdf | ||
| Attachment V - VHA Directive 1192.01.pdf | ||
| Attachment VII - RFI Form.pdf | ||
| Attachment III - Locations.pdf | ||
| 36C25024B0029_1.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 36C25024B0029:
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: _______238170___________________________
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 .