attachment C-Pre-Award Contractor Safety and Environmental Record Form.pdf
PDF 306 KB Posted
- Solicitation number
- 36C24824R0177
About this file
This document is an Attachment C - Pre-Award Contractor Safety and Environmental Record Form, which is part of a federal contract solicitation.
The form requires the contractor to provide information about their safety and environmental record, including number of man-hours, OSHA recordable cases, DART rate, and any OSHA or EPA violations within the last 3 years. The contractor must also provide their company's Insurance Experience Modification Rate (EMR) for the past 3 years, which must be 1 or less. The solicitation is for the renovation of the 6th floor west wing of Building 1 at the James A. Haley VA Hospital in Tampa, Florida, including demolition, new construction, and installation of various systems. The solicitation number is 36C24824R0177 and the agency is the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8.
View the file
Other files
Show all 22
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
Attachment C
Safety or Environmental Violations and Experience Modification Rate
Pre-Award Contractor Safety and Environmental Record Form
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 2021 2022
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 or any EPA violations 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. Who administers your company’s Safety and Health Program?
3. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of 1 or less is required): _____________
Please see FOPR 36C24821R0126 http://www.osha.gov/pls/publications/publication.html
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
File details come from the government source that posted it. Updated .