Attachment 5 - EMR Attachment.pdf
PDF 189 KB Posted
- Attached to
- Z1DA--Relocate IT Offices 539-21-208
- Solicitation number
- 36C25021B0065
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and details of a federal contract opportunity to relocate IT offices at a Veterans Affairs medical center. The form requests contact information and safety data including employee hours, OSHA recordable incidents, and insurance experience modification rate from prospective contractors. The related federal contract opportunity is to renovate existing space for IT offices including demolition, HVAC, electrical, and other construction and site work. The solicitation number is provided, along with an estimated budget range of $500,000 to $1,000,000. The work location is specified as the Cincinnati VA Medical Center, and tentative dates are given for issuing the invitation for bids, bid opening, and project completion. Plans and specifications will be available with the solicitation, and the set-aside is for Service-Disabled Veteran Owned Small Businesses.
View the file
Other files
Show all 49
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Pre-Award Contractor Safety and Environmental Record
Evaluation Form Information provided below is current and applicable to Solicitation # 36C25021B0065.
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 .