Attachment D Pre-Award Contractor Safety and Environmental Record Form.pdf
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- Solicitation number
- 36C24822R0002
About this file
This document provides details for a federal contract solicitation to replace variable air volume assemblies at the West Palm Beach Veterans Affairs Medical Center. The solicitation seeks to replace approximately 1,184 variable air volume boxes in the main hospital and 119 boxes in the community living center. Interested parties must register in the System for Award Management and the solicitation is anticipated to be issued on or about October 28, 2021 with a response due date of December 2, 2021. The contract is set aside for service-disabled veteran-owned small businesses and has an estimated value between $10-20 million. The selected contractor will provide all labor, materials, tools and equipment to replace the variable air volume assemblies, reheat coils, control valves, direct digital controls and thermostats. There is also a deductive item to remove the work associated with the community living center boxes from the scope of work.
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Attachment D
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 2018 2019 2020
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 solicitation 36C24822R0002 proposal instructions, Part II, paragraph 6 for instructions.
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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