Attachment III - EMR.docx
DOCX document 14 KB Posted
- Attached to
- Y1DA--CON - Upgrade A Wing & D Wing Elevators - 583-22-101 Federal contract opportunity
- Solicitation number
- 36C25025B0003
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form related to Solicitation # 36C25025B0003. It requires the contractor to provide information on their OSHA 300 forms, including the number of man-hours, number of cases involving days away from work, their DART rate, and any OSHA violations within the last 3 years. The contractor must also provide their 6-digit NAICS code, who administers their safety and health program, and their current Insurance Experience Modification Rate (EMR). The related federal contract opportunity is for the Upgrade A Wing & D Wing Elevators - 583-22-101, solicited by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25025B0003 0004.docx | DOCX document | |
| 36C25025B0003 0003.docx | DOCX document | |
| Sign in Sheet.pdf | ||
| 36C25025B0003 0002.docx | DOCX document | |
| Bid Schedule.docx | DOCX document | |
| 36C25025B0003 0001.docx | DOCX document | |
| Attachment X - Sole Sources-Motion Control.pdf | ||
| Attachment IX - Sole Sources-Imperial Electric.pdf | ||
| Attachment VIII - PCRA - Elevator Modification.pdf | ||
| Attachment VI - Specifications.pdf | ||
| Attachment IV - VHA Directive 1192-01.pdf | ||
| 36C25025B0003.docx | DOCX document | |
| Attachment V - Drawings.pdf | ||
| Attachment I - Wage Determination.pdf | ||
| Attachment VII - NEPA Documentation.pdf | ||
| Attachment II - RFI Template.doc | DOC 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 # 36C25025B0003.
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| CATEGORY |
| 2021 |
| 2022 |
| 2023 |
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 an 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: 238290 |
| 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 .