Attachment 11 - Safety or Environmental Violations.pdf
PDF 200 KB Posted
- Attached to
- DB - Replace CLC3 Finishes - Lake City
- Solicitation number
- 36c24823r0142
About this file
This document contains a pre-award contractor safety evaluation form and information about a related federal contract opportunity for construction services. The evaluation form requests details on the contractor's safety record over the past three years, including OSHA reportable incidents and violations. It also asks for the contractor's NAICS code, who administers their safety program, and their insurance experience modification rate. The related federal contract opportunity is a solicitation from the Department of Veterans Affairs to replace finishes at the CLC3 facility in Lake City. Interested contractors can submit questions by June 26th and phase one proposals are due by July 5th, 2023. The solicitation number and brief description of the project are provided.
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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 .