Attach IV - EMR.docx
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- Solicitation number
- 36C25025Q0416_1
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation #36C25025Q0416, related to a Veterans Affairs Medical Center project for upgrading parking garage sump pumps. The form requires contractors to provide detailed safety and environmental performance metrics, including OSHA 300 form data for 2022-2024, such as man-hours, workplace injury cases, days away from work, and DART (Days Away, Restricted, or Transferred) rates. Contractors must also disclose any serious, willful, or repeat OSHA violations within the past three years and provide supporting documentation.
The associated federal contract opportunity involves removing two failed sump pumps and reinstalling two new sump pumps with associated system components at the Richard L. Roudebush Veterans Affairs Medical Center. The project is classified under NAICS code 236220 and is being managed by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10. Bidders are required to complete the safety evaluation form, which includes providing details about their company's safety and health program administration and insurance Experience Modification Rate (EMR).
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25025Q0416.
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| CATEGORY |
| 2022 |
| 2023 |
| 2024 |
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 an 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 .