attachment C-Pre-Award Contractor Safety and Environmental Record Form (EMR).pdf
PDF 306 KB Posted
- Attached to
- Y1DA--FY23: NRM-Tier 2 (PROJ: 673-14-104) BB Renovate and Replace Transportation Equipment Building 1
- Solicitation number
- 36C24823R0186
About this file
This document is a pre-award contractor safety and environmental record form required as an attachment to a solicitation. The form collects safety data including number of man hours, OSHA recordable injuries, days away from work cases, and DART rates for the past three years. It also requests copies of the contractor's OSHA 300 and 300A forms, information on who administers its safety program, and experience modification rates. The related federal contract opportunity is for renovating and replacing a transportation equipment building at a Department of Veterans Affairs medical center under solicitation number 36C24823R0186.
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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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