ATTACHMENT D - EMR.pdf
PDF 145 KB Posted
- Solicitation number
- 36C24824R0014
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity to upgrade the HVAC system at a Department of Veterans Affairs data center. The evaluation form requests information from bidders including OSHA recordable incident rates, NAICS code, safety program administration, and experience modification rates over three years. Bidders must also provide documentation of any OSHA violations. The related federal contract opportunity is solicitation number 36C24824R0014 to provide design-build services for upgrading the HVAC system at the Lakemont Data Center under the Veterans Health Administration Veterans Integrated Service Network 8. Relevant response dates or award timing are not specified.
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Text version
EMR FORM
FORM FOR BIDDER/OFFEROR TO
COMPLETE & SUBMIT WITH PROPOSAL
Pre-Award Contractor Evaluation Form
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2019 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 within the last 3 years. Please attach explanation for any violations. (Four serious, one repeat, or one willful disqualifies the contractor.)
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. Provide your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor): _____________ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .