Attachment 09 - Safety or Environmental Violations and Experience Modification Rate EMR Form (1 page).pdf
PDF 151 KB Posted
- Attached to
- Y1DA--Replace Elevator Systems (DB)
- Solicitation number
- 36C24823R0060
About this file
This document contains a pre-award safety evaluation form and details of a federal solicitation to replace elevator systems at a Veterans Affairs medical center. The one-page safety evaluation form requests contact information and safety data from 2019 to 2021 including total man hours, OSHA recordable incidents, days away from work rates, and serious violations. It also asks for the company's NAICS code, safety program administrator, and experience modification rate.
The related federal solicitation provides an opportunity to design and construct a replacement elevator system at the Malcolm Randall Veterans Affairs Medical Center. Services include evaluating existing elevators, shafts, components, and integrated systems to upgrade the complete elevator system. The solicitation is issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8.
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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 2019 2020 2021
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 .