Attachment IV - EMR.pdf
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- Solicitation number
- 36C25024Q0035
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for federal solicitation number 36C25024Q0035 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10. The form requests information on the contractor's OSHA 300 forms from 2020 to 2022 including man hours, cases involving days away from work or restricted activity, days away restricted or transferred rate, and OSHA violations. It also requests the contractor's NAICS code for this acquisition, who administers their safety and health program, and insurance experience modification rate. Attached documents include OSHA 300 and 300a forms.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
The information provided below is current and applicable to Solicitation # 36C25024Q0035.
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 (job site and office).
Number of cases involving days away from work, restricted activity, or both (Columns 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: 237130
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate (EMR):
http://www.osha.gov/pls/publications/publication.html
Pre-Award Contractor Safety and Environmental Record Evaluation Form
File details come from the government source that posted it. Updated .