Attachment 05 - Safety or Environmental Violations and Experience Modification Rate EMR Form (1 page).pdf

PDF 108 KB Posted

Attached to
Y1DB--Expand Interventional Radiology Suite Federal contract opportunity
Solicitation number
36C24823R0162
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8

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This document contains a pre-award contractor safety and environmental record evaluation form for the federal contract opportunity to expand an interventional radiology suite at a Veterans Affairs medical center. The form requests contact information and safety data from the previous three years, including total man hours, OSHA recordable incidents, days away from work or job transfer/restriction rates, and any serious violations. It also asks for the company's six-digit NAICS code, safety program administrator, and experience modification rate from its insurance provider. Supporting documentation of OSHA forms and rates are required to be attached for evaluation.

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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): _____________ 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 .