Attachment II - EMR.pdf
PDF 138 KB Posted
- Solicitation number
- 36C25023B0023
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for a federal solicitation. The solicitation is for exterior painting services at various buildings for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10, identified as solicitation number 36C25023B0023. The evaluation form requests safety and insurance information from bidding contractors, including OSHA 300 and 300a forms for the previous three years detailing man-hours worked, days away from work cases, and incident rates. It also requests the company's NAICS code, who administers its safety program, and its experience modification rate for insurance purposes.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25023B0023 0005.docx | DOCX document | |
| Attachment XII - FINAL CORRECTED Combined Specifications_ (003).pdf | ||
| 36C25023B0023 0004.docx | DOCX document | |
| Attachment XI - CORRECTED Combined Specifications_.pdf | ||
| 36C25023B0023 0003.docx | DOCX document | |
| Attachment VIII - Pre-Bid RFI QUESTIONS and ANSWERS.docx | DOCX document | |
| Attachment IX - Site Walk Sign In Sheet.pdf | ||
| Attachment X - BID SCHEDULE FINAL.docx | DOCX document | |
| 36C25023B0023 0002.docx | DOCX document | |
| 36C25023B0023 0001.docx | DOCX document | |
| Attachment VI - Combined Specifications .pdf | ||
| Attachment III - DBA WD.pdf | ||
| Attachment V - VHA Directive 1192-01.pdf | ||
| Attachment VII - Drawings.pdf | ||
| Attachment IV - Limitations on Subcontracting - Certificate of Compliance.pdf | ||
| ATTACHMENT I - RFI.pdf | ||
| 36C25023B0023_1.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25023B0023.
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
CATEGORY 2019 2020 2021
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):
http://www.osha.gov/pls/publications/publication.html
Pre-Award Contractor Safety and Environmental Record Evaluation Form
File details come from the government source that posted it. Updated .