Attachment II - EMR.pdf
PDF 480 KB Posted
- Attached to
- N041 - Bldg 305 Chiller Replacement Federal contract opportunity
- Solicitation number
- 36C25025Q0780
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for solicitation number 36C25025Q0780. The form requires contractors to provide comprehensive safety and health information as part of their proposal submission, including basic company contact details and identification of who administers the company's safety program.
The form mandates completion of a detailed safety performance table covering 2021-2023, requiring contractors to report total man hours (jobsite and office), number of cases involving days away from work or restricted activity based on OSHA 300 forms, calculation of the Days Away Restricted or Transferred (DART) rate, and documentation of any serious, willful, or repeat OSHA violations within the last three years with explanations attached. Contractors must also provide their six-digit NAICS code for the acquisition, submit copies of OSHA 300 and 300a forms, and report their Insurance Experience Modification Rate (EMR). This evaluation form serves as a pre-award assessment tool to evaluate contractor safety performance and compliance history before contract award.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25025Q0780 0003.pdf | ||
| Attendance Record Site Visit - 305 Chiller Replacement.pdf | ||
| 36C25025Q0780 P0002.pdf | ||
| 36C25025Q0780 0001.pdf | ||
| Attachment VI - VA NOTICE OF TOTAL SET-ASIDE FOR VERIFIED SERVICE-DISABLED VETERAN-OWNED SMALL BUSINESSES.docx | DOCX document | |
| Attachment IV - Limitation on Subcontracting Cert.pdf | ||
| Attachment III - RFI.pdf | ||
| Attachment I - DBA OH20250081.pdf | ||
| Attachments V - vha directive 1192.01.pdf | ||
| 36C25025Q0780_1.pdf | ||
| Attachment I - SCA 2015-4731.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 # 36C25025Q0780
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2021 2022 2023
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.
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: __________________________________
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 .