Attachment III - EMR.docx
DOCX document 15 KB Posted
- Attached to
- Z1DA--Repair Roof 36 - 583-25-514
- Solicitation number
- 36C25025Q0588
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation #36C25025Q0588, issued by the Department of Veterans Affairs Veterans Health Administration. The form requires potential contractors to provide detailed safety and performance data, including OSHA 300 Forms documenting man-hours, workplace injury cases, days away from work, and DART (Days Away, Restricted, or Transferred) rates for the years 2020-2022. Contractors must also disclose their six-digit NAICS code (236220), identify who administers their Safety and Health Program, and report their Insurance Experience Modification Rate (EMR).
The solicitation appears to be for a roof repair project (Z1DA--Repair Roof 36 - 583-25-514) within Veterans Integrated Service Network 10. The form mandates that contractors attach explanations for any OSHA violations and provide copies of OSHA 300 and 300a Forms, demonstrating a strong emphasis on safety performance and compliance as part of the contractor selection process.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25025Q0588 0001.docx | DOCX document | |
| Pre-Bid Site Visit Sign-In Sheet - 583-25-54.pdf | ||
| 36C25025Q0588_1.docx | DOCX document | |
| Attachment VI - Communication Equipment List.pdf | ||
| Attachment IV - VHA Directive 1192-01.pdf | ||
| Attachment II - RFI Template.doc | DOC document | |
| Attachment VII - Roof 36 Access Route.pdf | ||
| Attachment I - Wage Determination - DBA.pdf | ||
| Attachment V - VA Notice of Limitations on Subcontracting.docx | DOCX document | |
| Attachment VIII - Specifications.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 # 36C25025Q0588.
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 .