attachment C-Pre-Award Contractor Safety and Environmental Record Form (EMR).pdf
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- Attached to
- Y1DA--FY24: NRM (PROJ: 673-23-104) DB Install Fall Protection Anchorage and Guardrails for Bldg 1 and 2
- Solicitation number
- 36C24824R0016
About this file
This document contains a pre-award contractor safety and environmental record form. The form requests information from contractors including number of man hours, OSHA recordable cases, days away from work rates, and safety violations over the past three years. Contractors must provide documentation including OSHA 300 and 300A forms and disclose their experience modification rates. The related federal contract opportunity is for fall protection anchorage and guardrail installation for two buildings from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8.
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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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