Attachment 7 - EMR.docx
DOCX document 14 KB Posted
- Attached to
- Z1DA--Remodel Front Entrance (Cin) 539-21-211
- Solicitation number
- 36C25022B0002
About this file
This solicitation is for a remodel of the front entrance at the Cincinnati VA Medical Center. The project has an estimated value between $500,000 and $1 million, and the NAICS code is 236220 with a small business size standard of $39.5 million. This is a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses, which must be registered and verified in VIP and SAM databases. Offerors must be able to provide safety and environmental violation records and experience modification rate documentation prior to award. The single site visit will take place on November 29, 2021, and questions must be submitted by the date specified in the solicitation. The duration of the project may not exceed 300 calendar days from notice to proceed. Performance and payment bonds will be required.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form Information provided below is current and applicable to Solicitation # 36C25022B0002.
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): ____________________________ |
File details come from the government source that posted it. Updated .