Attachment III - EMR.docx
DOCX document 15 KB Posted
- Attached to
- Y1DZ--Replace Grease Duct Canteen 610A4-25-504
- Solicitation number
- 36C25025Q0453
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation #36C25025Q0453, issued by the Department of Veterans Affairs Veterans Health Administration. The form requires potential contractors to provide detailed safety and performance information, including OSHA 300 Forms data for 2020-2022, covering man-hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and any OSHA violations within the past three years.
The solicitation is for a project to replace a grease duct at Canteen 610A4-25-504, with a specific NAICS code of 236220. Contractors must submit documentation including OSHA 300 and 300a Forms, provide their company's Safety and Health Program administrator, and disclose their Insurance Experience Modification Rate (EMR). The form serves as a pre-award assessment tool to evaluate a contractor's safety performance and environmental record before potential contract award.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25025Q0453 0003.docx | DOCX document | |
| Pre Bid Sign In Sheet.pdf | ||
| 36C25025Q0453 0002.docx | DOCX document | |
| Canteen fan.pdf | ||
| 36C25025Q0453 0001.docx | DOCX document | |
| Attachment VI - Drawing 2.pdf | ||
| Attachment IV - VHA Directive 1192-01.pdf | ||
| Attachment II - RFI Template.doc | DOC document | |
| Attachment I - Wage Determination.pdf | ||
| Attachment VII - Drawing 1.pdf | ||
| Attachment VIII - Specifications.pdf | ||
| 36C25025Q0453_1.docx | DOCX document | |
| Attachment V - VA Notice of Limitations on Subcontracting.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 # 36C25025Q0453.
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 .