Attachment V - EMR Form-36C25024B0068.pdf
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- Solicitation number
- 36C25024B0068
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form related to Solicitation 36C25024B0068 for the Department of Veterans Affairs (VA) Northern Indiana Healthcare System. The form requires the contractor to provide information on their company's OSHA 300 forms, including number of man-hours, days away/restricted/transferred cases, DART rate, and any OSHA violations within the last 3 years. The contractor must also provide their North American Industry Classification System (NAICS) code, details on who administers their safety and health program, and their Insurance Experience Modification Rate (EMR). This information is required to evaluate the contractor's safety and environmental record as part of the pre-award process for the solicitation. The solicitation is for a project to correct water intrusion at Building 8 on the VA Northern Indiana Healthcare System's Marion campus, with a 365-day period of performance.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C25024B0068:
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 a 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): ____________________________
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .