Attachment II - EMR - 539-23-201.docx
DOCX document 25 KB Posted
- Solicitation number
- 36C25023B0046
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for solicitation number 36C25023B0046 to resurface and stripe a parking lot at Fort Thomas, Kentucky. The form requests information on the contractor's man-hours and OSHA recordable incidents over the past three years, as well as explanations for any serious violations. It also asks for the contractor's NAICS code, who administers its safety program, and insurance experience modification rate. The related federal contract opportunity is to resurface and stripe the parking lot at Fort Thomas, Kentucky under project number 539-23-201, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10.
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Other files
| File | Type | Posted |
|---|---|---|
| Bid and Deduct Schedule.pdf | ||
| 36C25023B0046 0003.docx | DOCX document | |
| 36C25023B0046 0002.docx | DOCX document | |
| 36C25023B0046 0001.docx | DOCX document | |
| Attachment I - Site Visit Log 5.23.23.pdf | ||
| 36C25023B0046_1.docx | DOCX document | |
| Attachment III - Limitations on Subcontracting Certificate of Compliance.docx | DOCX document | |
| Attachment V - RFI 539-23-201.docx | DOCX document | |
| Attachment VII - Drawings.pdf | ||
| Attachment VI - Specifications.pdf | ||
| Attachment IV - VHA Directive 1192-01.pdf | ||
| Attachment I - WD Campbell County - 539-23-201.pdf |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25023B0046.
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 within the last 3 years. Please attach an 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. | Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 236220 |
| 3. | Who administers your company’s Safety and Health Program? ____________________________ |
| 4. | Company’s Insurance Experience Modification Rate (EMR): ____________________________ |
File details come from the government source that posted it. Updated .