Appendix 2- Contractor Certification Regarding Safety and Environmental- 589-22-885 03.docx
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- Solicitation number
- 36C25524R0097
About this file
This document is an Appendix 2 - Pre-Award Contractor Safety and Environmental Record Evaluation Form related to Solicitation 36C25524R0097 issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 15. The form requires the contractor to provide information about their OSHA 300 injury and illness records, including number of man hours, cases involving days away from work, their Days Away, Restricted, or Transferred (DART) rate, and any OSHA violations within the last 3 years. The contractor must also provide their North American Industry Classification System (NAICS) code, the administrator of their Safety and Health Program, and their Insurance Experience Modification Rate (EMR). This information is required to evaluate the contractor's safety and environmental record as part of the pre-award process for this contract opportunity.
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APPENDIX 2 - Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C25524R00097:
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2020 |
| 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 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): ____________________________
File details come from the government source that posted it. Updated .