Attachment 10 - EMR.docx
DOCX document 14 KB Posted
- Attached to
- Z1DA--Renovate Auditorium & C-1202 583-22-509
- Solicitation number
- 36C25022B0068
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity for renovating an auditorium and room C-1202. The evaluation form requests contact information and safety data including man hours, OSHA recordable incidents, DART rates, and serious violations over the past three years. It also asks for the company's NAICS code, who administers its safety program, and insurance EMR. The related federal contract opportunity is solicited by the Department of Veterans Affairs Veterans Health Administration VISN 10 for renovating an auditorium and room C-1202 at an unspecified location.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form Information provided below is current and applicable to Solicitation # 36C25022B0068.
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 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 .