Attachment VI - EMR Form.pdf
PDF 131 KB Posted
- Solicitation number
- 36C25025B0013
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form associated with Solicitation 36C25025B0013 for the Department of Veterans Affairs. The form requires contractors to provide detailed safety performance data including OSHA 300 Form information for 2021-2023, covering man-hours worked, cases involving days away from work or restricted activity, DART rates, and any OSHA violations. The NAICS code specified is 238220 (Plumbing, Heating, and Air-Conditioning Contractors).
The form requests specific documentation including OSHA 300 and 300a Forms, information about who administers the company's Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR). This appears to be a template requiring completion by potential contractors to evaluate their safety record prior to contract award. The form includes fields for basic company contact information including name, address, telephone, fax, email, and point of contact.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25025B0013 0002.pdf | ||
| 36C25025B0013 0001.pdf | ||
| Attachment II - Site Differing.pdf | ||
| 36C25025B0013.pdf | ||
| Attachment III - Minimum_Property_Requirement.pdf | ||
| Attachment IV - DBA-IN20230002.pdf | ||
| Attachment V - VHA Directive 1192.01.pdf | ||
| Attachment VII - RFI Form.pdf | ||
| Attachment I - Standards Specification.pdf | ||
| 36C25025B0013_1 Correction.docx | DOCX document | |
| 36C25025B0013_1.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
The information provided below is current and applicable to Solicitation 36C25025B0013:
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 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: _______238220___________________________
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 .