Attachment F - Safety of Environmental Violations and WMR Information 2 - pages.pdf
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- Solicitation number
- 36c26325b00130001
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for a federal contract related to a fire hydrant line break repair project at the Fargo VA Health Care System. The form requires contractors to provide detailed safety and environmental compliance information, including OSHA 300 Forms documentation for the past three years, covering metrics such as man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and any serious, willful, or repeat OSHA violations.
The document mandates that offerors submit their Experience Modification Rate (EMR) from their insurance carrier, with specific requirements for contractors with an EMR above 1.0 or those who are self-insured. Contractors must provide documentation explaining their safety record, including OSHA 300 and 300a Forms, their six-digit NAICS code (236220 for this acquisition), information about their safety and health program administrator, and their current EMR. This information will be used by the Department of Veterans Affairs to make an initial Determination of Responsibility for the contract, which involves repairing a fire hydrant line at the Fargo VA Health Care System.
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| File | Type | Posted |
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| 36C26325B0013 0001.pdf |
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Safety or Environmental Violations and Experience Modification Rate
All Offerors shall submit information pertaining to their past Safety and Environmental record.
The information must contain a certification that the bidder/offeror has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years. If such certification cannot be made, a Bidder/Offeror shall explain why and submit as much information as possible regarding the circumstances of its past safety and environmental record, including the number of EPA violations and/or the number of serious, repeat, and/or willful OSHA violations, along with a detailed description of those violations.
All Bidders/Offerors shall submit information regarding their current Experience Modification
Rate (EMR). This information shall be obtained from the Bidder’s/Offeror’s insurance carrier and be furnished on the insurance carrier’s letterhead. If a Bidder/Offeror’s EMR is above 1.0, Bidder/Offeror must submit a written explanation of the EMR from its insurance carrier furnished on the insurance carrier’s letterhead, describing the reasons for the EMR, and the anticipated date the EMR may be reduced to 1.0 or below.
Self-insured contractors or other contractors that cannot provide their EMR rating on insurance letterhead must obtain a rating from the National Council on Compensation Insurance, Inc.
(NCCI) by completing/submitting form ERM-6 and providing the rating on letterhead from
NCCI. Note: Self-insured contractors or other contractors that cannot provide EMR rating on insurance letterhead from the states or territories of CA, DE, MI, NJ, ND, OH, PA, WA, WY, and PR shall obtain their EMR rating from their state-run worker’s compensation insurance rating bureau.
If the NCCI cannot issue an EMR because the Bidder/Offeror lacks insurance history, Bidder/Offeror shall submit a letter indicating so from its insurance carrier furnished on the insurance carrier’s letterhead and include a letter from the NCCI indicating that is has assigned
Bidder/Offeror a Unity Rating of 1.0.
The above information, along with other information obtained from Government systems, such as the OSHA and EPA online inspection history databases, will be used to make an initial
Determination of Responsibility.
This requirement is applicable to all subcontracting tiers, and prospective prime contractors are responsible for determining the responsibility of their prospective subcontractors.
Safety or Environmental Violations and Experience Modification Rate
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ___________________________________________________
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 your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 236220
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 .