Attachment IV - EMR.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C25026B0004
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for a Department of Veterans Affairs contract (Contract #36C25025C0191). The form requires contractors to provide detailed safety and health information, including OSHA 300 Form data for 2022-2024, such as man-hours, workplace injury cases, days away/restricted work rates, and OSHA violation history.
The associated federal contract opportunity (Solicitation #36C25026B0004) involves repair and upgrade of medical air, gas, and vacuum systems for Veterans Health Administration Veterans Integrated Service Network 10. The form requests contractors to submit their six-digit NAICS code (236220), identify who administers their safety program, and disclose their company's Insurance Experience Modification Rate (EMR). Contractors must attach OSHA 300 and 300A forms and provide explanations for any serious, willful, or repeat OSHA violations within the past three years.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment XII - RFI Template.doc | DOC document | |
| Attachment VIII - Exhibit 2.pdf | ||
| Attachment XI - Exhibit 5.pdf | ||
| Attachment IX - Exhibit 3.pdf | ||
| Attachment VII - Exhibit 1.pdf | ||
| Attachment VI - Specifications.pdf | ||
| Attachment III - VA Notice of Limitations on Subcontracting.docx | DOCX document | |
| Attachment V - Drawings.pdf | ||
| Attachment I - Wage Determination.pdf | ||
| Attachment X - Exhibit 4.pdf | ||
| Attachment II - VHA Directive 1192-01.pdf | ||
| 36C25026B0004_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 Contract # 36C25025C0191.
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| CATEGORY |
| 2022 |
| 2023 |
| 2024 |
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 .