Attachment III - EMR.docx
DOCX document 14 KB Posted
- Attached to
- Conduct Boiler Tank Inspection 610A4-23-513
- Solicitation number
- 36C25023Q0493
View the file
Other files
| File | Type | Posted |
|---|---|---|
| RFI QA.docx | DOCX document | |
| Site Visit Sign-In Sheet.pdf | ||
| 36C25023Q0493 0001.docx | DOCX document | |
| WD.pdf | ||
| VHA Directive 1192 01.pdf | ||
| 36C25023Q0493 Sam.gov.docx | DOCX document | |
| Attachment II - RFI Form.doc | DOC document | |
| 852.219-75.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 # 36C25023Q0418.
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 .