attachment C-Pre-Award Contractor Safety and Environmental Record Form (EMR).pdf

PDF 306 KB Posted

Attached to
Z1DA--FY24: NRM (PROJ: 673-21-152) BB - Replace AHUs 22 and 23
Solicitation number
36C24824R0010
Issued by

About this file

Written by GovTribe AI ·

This document contains an attachment for a pre-award contractor safety and environmental record form. The form requests contact information for the contractor and details on safety incidents and violations over the past three years, including number of man hours, OSHA recordable incidents, days away from work, and any serious, willful, or repeat violations. It also asks for the contractor's experience modification rate for workers' compensation insurance and who administers the company's safety and health program. The related federal contract opportunity is for replacing air handling units 22 and 23 at a Department of Veterans Affairs medical center as part of project 673-21-152.

View the file

Other files

File Type Posted
SIGNING SHEET.jpg JPG image
36C24824R0010 0002.docx DOCX document
36C24824R0010 0001.docx DOCX document
36C24824R0010_2.pdf PDF
7C - SPECS - Replace AHUs 22 and 23 - 100 percent S and S Bid Documents for Construction.pdf PDF
7A - DAR - Replace AHUs 22 and 23 - 100 percent S and S Bid Documents for Construction.pdf PDF
Attachment A - Itemized Schedule of Values Cost Breakdown (1).pdf PDF
7B - Drawings - Replace AHUs 22 and 23 - 100 percent S and S Bid Documents for Construction.pdf PDF
36C24824R0010_2.docx DOCX document
Attachment B - Experience Information Sheet.pdf PDF
VA NOTICE OF LIMITATIONS ON SUBCONTRACTING.pdf PDF
WD_20154571_revision21.pdf PDF
SOW -.pdf PDF
Show all 13

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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 .