Attachment 05 - Contractor Safety.pdf
PDF 249 KB Posted
- Solicitation number
- 36C24825R0011
About this file
This document is an Attachment to a Solicitation for a federal contract opportunity. It is a Contractor Safety and Environmental Record Evaluation Form that must be completed by prospective contractors.
The form requires the contractor to provide information on their OSHA 300 and 300a forms, including the number of man-hours, cases involving days away from work, their DART rate, and any OSHA violations within the last 3 years. The contractor must also provide their 6-digit NAICS code, the administrator of their safety and health program, and their current Experience Modification Rate (EMR). This information will be used to evaluate the contractor's safety and environmental record as part of the pre-award process for the federal contract opportunity.
The related federal contract opportunity is a Solicitation (36C24825R0011) for a Design-Build project to Upgrade the Electrical System in the Kitchen, issued by the Department of Veterans Affairs, Veterans Health Administration, Veterans Integrated Service Network 8. Proposals for this opportunity are due on 12/06/2024.
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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 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 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 .