Attachemnt II - EMR Attachment.pdf

113 KB Posted

Attached to
Repair LG HVAC Bldg 3
Solicitation number
36C25025Q0693
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The document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation #36C25025Q0693. The form requires detailed safety and environmental performance information from potential contractors, including OSHA-related metrics for 2021-2023. Contractors must provide:

  1. OSHA 300 and 300a form documentation
  2. Total man-hours worked
  3. Number of workplace injury/restriction cases
  4. Days away, restricted, or transferred (DART) rate
  5. Number of serious, willful, or repeat OSHA violations
  6. Six-digit NAICS code
  7. Details on the company's Safety and Health Program administrator
  8. Company's Insurance Experience Modification Rate (EMR)

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Other files

File Type Posted
Attachments V - vha directive 1192.01.pdf PDF
Attachment III - RFI Attachment.pdf PDF
36C25025Q0693.pdf PDF
Attachment IV - Limitation on Subcontracting Cert.pdf PDF

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Pre-Award Contractor Safety and Environmental Record

Evaluation Form Information provided below is current and applicable to Solicitation # 36C25025Q0693

Company Name: ______________________________________________

Address: _____________________________________________________

Telephone: ______________________ Fax: ________________________

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 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):

http://www.osha.gov/pls/publications/publication.html

File details come from the government source that posted it. Updated .