Attachment IV - EMR Form.pdf
PDF 111 KB Posted
- Attached to
- Z1DA--Project # 539-21-111 - Upgrade Terminal Units Additional information available on page # 2.
- Solicitation number
- 36C25021B0125
About this file
This document contains a pre-award contractor safety and environmental record evaluation form along with details of a related federal contract opportunity for upgrade work. The evaluation form requests contact information and safety data from the past three years including total man hours, OSHA recordable incidents, days away from work rates, and serious violations. It also asks for North American Industry Classification codes and insurance experience modification rates. The related federal contract opportunity is for project number 539-21-111 to upgrade terminal units within the Veterans Health Administration Veterans Integrated Service Network 10. No further details are provided on requirements, response dates, or incumbent contractors.
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Pre-Award Contractor Safety and Environmental Record
Evaluation Form Information provided below is current and applicable to Solicitation # 36C25021B0125.
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2018 2019 2020
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 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):
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .