Attachment 4 - EMR Attachment.pdf
PDF 198 KB Posted
- Attached to
- Z1DA--Upgrade Air Handler Units 539-21-104 Federal contract opportunity
- Solicitation number
- 36C25021B0059
About this file
This document contains a pre-award contractor safety and environmental record evaluation form along with details of a related federal contract opportunity for upgrade of air handler units at a Veterans Administration medical center. The pre-award form requests a contractor's OSHA 300 forms from 2018-2020 with man hours, cases involving days away from work or restricted activity, days away from work rate, and serious, willful or repeat OSHA violations from the past three years. It also requests the contractor's NAICS code and information on its safety and health program administrator and experience modification rate. The related federal contract opportunity is a 100% set-aside for small businesses with a preference for service-disabled veteran-owned small businesses. The solicitation number is 36C25021B0059 for project 539-21-104 to upgrade air handler units at the Veterans Administration Cincinnati medical center. The NAICS code is 238220 for the $5-10 million project which must be completed within 730 calendar days of notice to proceed. Bonds will be required and the contractor must demonstrate no more than three serious or one repeat or willful OSHA or EPA violations in the past three years along with an experience modification rate of 1.0 or less.
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Text version
Pre-Award Contractor Safety and Environmental Record
Evaluation Form Information provided below is current and applicable to Solicitation # 36C25021B0059.
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2018 2019 2020 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):
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .