Prime EMR Information for Responsibility Determination (1 Page).doc
DOC document 55 KB Posted
- Solicitation number
- 36C26321R0102
About this file
This document contains a contractor safety and environmental record evaluation form for a solicitation to construct an air handling tower. The form requests information on company name, address, contact details, number of man hours worked from 2018 to 2021, OSHA recordable injury rates for those years, any serious OSHA violations in the last three years, and copies of the company's OSHA 300 and 300a forms. It also asks for the company's six-digit NAICS code for the work, who administers its safety and health program, and its insurance experience modification rate. The related federal contract opportunity is solicitation number 36C26321R0102 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 23 to construct an air handling tower set aside for service-disabled veteran-owned small businesses.
View the file
Other files
Show all 32
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
CONTRACTOR SAFETY AND ENVIRONMENTAL RECORD EVALUATION FORM
Information provided below is current and applicable to Solicitation: 36C26321R0102
Company Name: ___________________________________________________________ Address:
Telephone:
Fax:
Email:
Contact:
Utilizing the completed OSHA 300 Forms, please complete the table below:
| Category |
| 2018 |
| 2019 |
| 2020 |
| 2021 |
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 (Log of Work-Related
Injuries and Illnesses) and 300a Forms (Summary of Work-Related Injuries and Illnesses).
These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
1. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 236220
2. Who administers your company’s Safety and Health Program?
3. Company’s Insurance Experience Modification Rate (EMR):
FOR OFFICAL USE ONLY 7 of 18
File details come from the government source that posted it. Updated .