Attachment 7 - EMR.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C25023B0063
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity for repairing loading docks at a Veterans Affairs facility. The evaluation form requests the contractor's OSHA 300 forms and insurance experience modification rate for the past three years, and asks for the North American Industry Classification System code for the work. It relates to Solicitation Number 36C25023B0063, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10, for repairing loading docks at Building 174 located at a Veterans Affairs medical center. The contractor must submit the completed evaluation form and required attachments in response to the solicitation by the specified due date in order to be considered for the contract award.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form Information provided below is current and applicable to Solicitation # 36C25023B0063.
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): ____________________________ |
File details come from the government source that posted it. Updated .