Attachment 6 - EMR Form.docx
DOCX document 18 KB Posted
- Attached to
- Z2DA--Replace Dual Duct Boxes on Second Floor - 539-21-201 Federal contract opportunity
- Solicitation number
- 36C25026B0042
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Project 539-21-201, a Department of Veterans Affairs solicitation (36C25026B0042) to replace dual duct mixing boxes on the second floor of a Veterans Integrated Service Network 10 facility.
The form requires contractors to submit detailed safety and occupational health information including OSHA 300 and 300a forms covering man hours, DART rates (days away, restricted, or transferred cases), and serious violations for the years 2022 through 2025. Contractors must identify their six-digit NAICS code (238220), provide information about the administrator of their Safety and Health Program, and submit their company's Insurance Experience Modification Rate (EMR). The form also requests standard contractor information including company name, address, telephone, fax, email, and primary contact. This evaluation form serves as a pre-award screening mechanism to assess contractor safety performance and risk prior to contract award.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Atch RFI 6 life safety plan.pdf | ||
| Atch RFI 4 Lead Paint Report.pdf | ||
| Atch RFI 7 ACM SURVEY REPORT.pdf | ||
| 36C25026B0042 0002.docx | DOCX document | |
| 36C25026B0042_1.pdf | ||
| 36C25026B0042 0001.docx | DOCX document | |
| Attachment 4 - Drawings.pdf | ||
| Attachment 3 - Specs.pdf | ||
| Attachment 2 - VHA Directive 1192.01.pdf | ||
| Attachment 12 - Tridium Niagara Redacted.pdf | ||
| Attachment 8 - ICRA.pdf | ||
| Attachment 1 - OH20260082 01022026.pdf | ||
| Attachment 11 -Honeywell Siemens JCI Redacted.pdf | ||
| Attachment 10 - FX Controls Redacted.pdf | ||
| Attachment 9 - PCRA.pdf | ||
| Attachment 5 - VAAR 852.219-75.docx | DOCX document | |
| Attachment 7 - Request for Information.docx | DOCX document | |
| 36C25026B0042_1.docx | DOCX document |
Show all 18
On GovTribe
Work with this file on GovTribe
- 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 Project 539-21-201:
Company Name: Address: Telephone: Fax: Email: Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2022 |
| 2023 |
| 2024 |
| 2025 |
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: 238220
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 .