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

184 KB Posted

Attached to
Y1DA--BB - Renovate Common Area Restrooms
Solicitation number
36C24825R0119
Issued by

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This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for a federal contract opportunity. The one-page form requires contractors to provide detailed safety information, including:

  1. OSHA-related data for 2022-2024, such as total man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rate, and any serious, willful, or repeat OSHA violations. Contractors must attach their OSHA 300 and 300a Forms. Additionally, the form requests the company's six-digit NAICS code, information about who administers their Safety and Health Program, and their Insurance Experience Modification Rate (EMR). This form is part of the solicitation for the VA Medical Center restroom renovation project (Solicitation Number 36C24825R0119) at the Malcom Randall VA Medical Center in Gainesville, FL, with a 730-calendar day performance period.

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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 2022 2023 2024

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): _____________

VHATAMGammA Cross-Out

File details come from the government source that posted it. Updated .