Attachment III - EMR.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C25024B0056
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation # 36C25024B0056, which is for a contract opportunity with the U.S. Department of Veterans Affairs Veterans Health Administration to Correct Fire and Smoke Damper Deficiencies at a facility.
The form requires the contractor to provide information on their OSHA 300 forms, including the number of man-hours, cases involving days away from work, their Days Away, Restricted, or Transferred (DART) rate, and any OSHA violations within the last 3 years. The contractor must also provide their North American Industry Classification System (NAICS) code, the administrator of their safety and health program, and their Insurance Experience Modification Rate (EMR). The contractor must attach copies of their OSHA 300 and 300a forms.
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Other files
| File | Type | Posted |
|---|---|---|
| 2022 Damper Locations.pdf | ||
| 36C25024B0056 0002.docx | DOCX document | |
| IMG_0228.jpeg | JPEG file | |
| 36C25024B0056 0001.docx | DOCX document | |
| IMG_0227.jpeg | JPEG file | |
| 583-24-511 - Site Visit Summary.docx | DOCX document | |
| Bid Schedule.docx | DOCX document | |
| Attachment II - RFI Template.doc | DOC document | |
| 36C25024B0056_1.docx | DOCX document | |
| Attachment VI - Damper Corrections.pdf | ||
| Attachment V - Specifications.pdf | ||
| Attachment IV - VHA Directive 1192-01.pdf | ||
| Attachment I - Wage Determination.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 # 36C25024B0056.
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 .