Attachment 05 - Contractor Safety and EMR (1 page).pdf
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- Solicitation number
- 36C24824R0037
About this file
This document is a pre-award safety evaluation form for a federal construction contract opportunity with the Department of Veterans Affairs. The form requests safety and risk management information from bidding contractors, including OSHA 300 and 300A forms for the past three years detailing man-hours worked, injury cases, and DART and total case rates. It also asks for the contractor's NAICS code, safety program administrator, and experience modification rate. The related federal contract opportunity is for repair work on a CLC walkway and stairs at a VA facility, solicitation number 36C24824R0037, with responses due under the Y1DA fiscal year 2024 funding program.
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Text version
Solicitation Attachment
Safety or Environmental Violations and Experience Modification Rate
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 2021 2022
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: __________________________________
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 .