Attachment 07 - Safety or Environmental Violations and Experience Modification Rate EMR Form (1 page).pdf
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- Solicitation number
- 36C24824R0055
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and requests information related to a federal contract opportunity to install patio windows at a mental health ward.
The form requests the contractor's name, address, contact information, and North American Industry Classification System code for the acquisition. It asks for man-hours and OSHA recordable incident rates for the past three years, as well as any serious, willful, or repeat OSHA violations and the administer of the company's safety program. Contractors must also provide their insurance experience modification rate and attach copies of their OSHA 300 and 300A forms.
The related federal contract opportunity is issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8 under solicitation number 36C24824R0055 to install patio windows at a mental health ward.
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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 .