attachment C-Pre-Award Contractor Safety and Environmental Record Form.pdf
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- Solicitation number
- 36C24825R0009
About this file
This document is a Solicitation for a federal contract opportunity issued by the Department of Veterans Affairs, Veterans Integrated Service Network 8. The contract is for the installation of Next-Gen Wi-Fi upgrades at the James A. Haley VA Hospital in Tampa, FL under Project Number 673-25-704. The solicitation has an estimated value between $250,000 and $500,000, and the performance period is 180 calendar days. It is a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses (SDVOSBs) verified by the Veteran Small Business Certification (sba.gov). Key requirements include the contractor having 5 years of comparable hospital work experience, state certification as a network technician company, and technicians holding certified technician licenses. Proposals are due by December 8, 2024 and will be evaluated on factors of past performance, technical/management approach, and price. Offerors must submit their current Experience Modification Rate, which cannot exceed 1.0, along with their proposal.
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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 |
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