Attachment III - EMR.docx
DOCX document 14 KB Posted
- Attached to
- Z1DA--Replace Overhead Dock Doors 610A4-24-503 Federal contract opportunity
- Solicitation number
- 36C25024Q0142
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for a federal solicitation to replace overhead dock doors. The form requests information on the contractor's OSHA 300 forms from 2020 to 2022, including man-hours, days away from work cases, restricted activity cases, and DART rates. It also asks for details on any serious, willful, or repeat OSHA violations in the past three years. The contractor must provide its six-digit NAICS code for the work and identify its safety program administrator. Additionally, the contractor is to disclose its company insurance experience modification rate. The related federal contract opportunity is for solicitation number 36C25024Q0142 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10 to replace overhead dock doors at location 610A4-24-503.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25024Q0142 0002.docx | DOCX document | |
| Attachment IV - VHA Directive 1192-01.pdf | ||
| Attachment II - RFI Template.doc | DOC document | |
| Attachment I - Wage Determination.pdf | ||
| 36C25024Q0142_1.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 # 36C25024Q0142_1.
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: 238290 |
| 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 .