Attachment III - EMR 583-24-201.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C25024B0040_1
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form related to Solicitation # 36C25024B0040 for the Department of Veterans Affairs (VA) to install mental health safety improvements at the 5th Floor Inpatient Mental Health Unit. The form requires the contractor to provide information on their OSHA recordkeeping, including number of man-hours, cases involving days away from work, days away/restricted/transferred (DART) rate, and any serious, willful, or repeat OSHA violations in the last 3 years. The contractor must also provide their North American Industry Classification System (NAICS) code, the name of the administrator of their safety and health program, and their current Insurance Experience Modification Rate (EMR). The project involves updating room finishes and installing new ligature-resistant plumbing fixtures to bring the unit into compliance with the Mental Health Environment of Care Checklist. The contract is being solicited by the VA Veterans Integrated Service Network 10.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25024B0040 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 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 .