A0002_Attachment E_EMR Form.pdf
PDF 128 KB Posted
- Solicitation number
- 36C25623R0120
About this file
This document contains a pre-award contractor evaluation form and details for a federal contract opportunity for painting and repair services at a Department of Veterans Affairs medical facility. The form requests safety and insurance information from prospective bidders, including OSHA 300 and 300a forms for the previous three years, NAICS code, safety program administrator, and experience modification rates. The related federal contract opportunity is a solicitation from the Veterans Health Administration to provide painting and repair services at the John L. McClellan Memorial Hospital. Relevant details include the solicitation number, brief description of services required, and issuing agency.
View the file
Other files
Show all 13
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
36C25623R0120
EMR FORM
FORM FOR BIDDER/OFFEROR TO
COMPLETE & SUBMIT WITH PROPOSAL
Pre-Award Contractor Evaluation Form
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. (Four serious, one repeat, or one willful disqualifies the contractor.)
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 your 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) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor):
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .