attachment C-Pre-Award Contractor Safety and Environmental Record Form (EMR).pdf
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- Solicitation number
- 36C24824R0011
About this file
This document contains an attachment for a pre-award contractor safety and environmental record form. The form requests contact information and safety records for prospective contractors, including number of man hours, OSHA recordable cases, days away from work rates, and any serious safety or environmental violations over the past three years. It also asks for the contractor's experience modification rate for workers' compensation insurance and who administers their safety and health program. The related federal contract opportunity is for replacing an air handling unit at a Department of Veterans Affairs medical center in 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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