Attachment 05 - Contractor Safety and EMR (1 page).pdf

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Attached to
Y1DA-- (PROJ: 573-24-600) DB Renovate Dental Laboratory E263
Solicitation number
36C24824R0044
Issued by

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This document contains a pre-award contractor safety evaluation form and details of a related federal contract opportunity for dental laboratory renovation services. The evaluation form requests safety-related information from prospective contractors, including OSHA recordable incident rates for the past three years, NAICS code, safety program administration details, and experience modification rate. The related federal contract opportunity is a solicitation from the Department of Veterans Affairs for project number 573-24-600 to renovate the dental laboratory at building E263. The solicitation number and agency details are provided.

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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 .