Attachment III - EMR.docx
DOCX document 14 KB Posted
- Attached to
- Z1DA--Upgrade Mental Health Restrooms 610-24-511
- Solicitation number
- 36C25024B0046
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and details for a related federal contract opportunity with the Department of Veterans Affairs to upgrade mental health restrooms. The evaluation form requests contact information and safety data including man-hours, OSHA recordable incidents, days away from work rates, and violations over the past three years. It also asks for the company's North American Industry Classification System code and information on its safety program administrator and experience modification rate for insurance. The related federal contract opportunity is solicitation number 36C25024B0046 to upgrade mental health restrooms at a Veterans Affairs facility for Veterans Integrated Service Network 10.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25024B0046 0003.docx | DOCX document | |
| Bid Schedule.docx | DOCX document | |
| 36C25024B0046 0002.docx | DOCX document | |
| AS102 Revision.pdf | ||
| Pre-Bid Site Visit Sign-In Sheet.pdf | ||
| GI103 Revision.pdf | ||
| 36C25024B0046 0001.docx | DOCX document | |
| Attachment VI - Combined Specs.pdf | ||
| Attachment IV - VHA Directive 1192-01.pdf | ||
| 36C25024B0046_1.docx | DOCX document | |
| Attachment I - Wage Determination.pdf | ||
| Attachment II - RFI Template.doc | DOC document | |
| Attachment V - Drawings.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 # 36C25024B0046.
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 .