Attachment IV - EMR.pdf
PDF 139 KB Posted
- Solicitation number
- 36C25024B0065
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form related to Solicitation # 36C25024B0065 issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10. The form requests the contractor to provide information on their OSHA 300 forms, including the number of man-hours, days away/restricted/transferred cases, DART rate, and any OSHA violations within the last 3 years. The contractor is also required to provide their 6-digit NAICS code, who administers their safety and health program, and their Insurance Experience Modification Rate (EMR). This information is used to evaluate the contractor's safety and environmental record as part of the pre-award process for the federal contract opportunity to replace an SPS air handler and install a humidification system.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25024B0065 0001.docx | DOCX document | |
| RFI Questions and Answers.pdf | ||
| ATTACHMENT V - RFI Template.pdf | ||
| Attachment VI - VHA Directive 1192-01.pdf | ||
| Attachment VII - Limitations on Subcontracting - Certificate of Compliance.pdf | ||
| 36C25024B0065.docx | DOCX document | |
| ATTACHMENT I - Specs.pdf | ||
| ATTACHMENT II - Drawings.pdf | ||
| ATTACHMENT III - DBA 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 # 36C25024B0065.
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: 238220
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 .