Attachment II - EMR.pdf
PDF 139 KB Posted
- Solicitation number
- 36C25024B0024
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for solicitation number 36C25024B0024 to replace building 1 penthouse air handling unit 610A4-25-219 at a Veterans Affairs medical center. The form requests contact information and safety data including man-hours, OSHA recordable incidents, days away from work rates, and serious violations over the past three years. It also asks for the company's NAICS code, safety program administrator, and experience modification rate for insurance purposes.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
The information provided below is current and applicable to Solicitation # 36C25024B0024.
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 (job site and office).
Number of cases involving days away from work, restricted activity, or both (Columns 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 a 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):
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 .