Attachment 7 - EMR.docx

DOCX document 14 KB Posted

Attached to
Z1DA--Replace Roofs Buildings 32, 33 & 34 610-23-515
Solicitation number
36C25023B0034
Issued by

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Other files

File Type Posted
36C25023B0034 0001 Amendment.docx DOCX document
610-23-515 Replace Roofs Buildings 32 33 34 Pre Bid Site visit.pdf PDF
610-23-515 - Combined Specs.pdf PDF
RFI Form-36C25023B0034.docx DOCX document
WD.pdf PDF
610-23-515 - COMBINED DRAWINGS.pdf PDF
VAAR 852.219-75 VA Notice of Limitations on Subcontracting (JAN 2023).pdf PDF
VHA_Directive_1192.pdf PDF
36C25023B0034_1.pdf PDF
610-23-515 Replace Roofs Buildings 32 33 34- OTFOC Sole Source Revised (002).pdf PDF

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Pre-Award Contractor Safety and Environmental Record Evaluation Form Information provided below is current and applicable to Solicitation # 36C25023B0034.

Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________

1. Utilizing your OSHA 300 Forms, please complete the following information:

Category
2022
2021
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): ____________________________

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