Attachment 05 - Safety or Environmental Violations and Experience Modification Rate EMR Form (1 page).pdf
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- Attached to
- Z2DA--Provide Emergency Backup to Standby Power for Motor Control Center at Chiller Plant
- Solicitation number
- 36C24823R0163
About this file
This document contains a pre-award contractor safety evaluation form and information on a related federal contract opportunity for emergency backup power services. The evaluation form requests details on the contractor's safety record over the past three years, including OSHA reportable incidents, days away from work, and any violations or citations. It also asks for the contractor's NAICS code and insurance experience modification rate.
The related federal contract opportunity is to provide construction services for an emergency backup power system at a VA medical facility. The project involves installing automatic transfer switches and feeders to provide backup power from an on-site generator to the chiller plant motor control center. It will also include SCADA monitoring connectivity. The requirement is being solicited by the VA Caribbean Healthcare System under VISN 8 for an undisclosed period of performance.
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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): _____________ http://www.osha.gov/pls/publications/publication.html http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .