Attachment IV - EMR Form.pdf
PDF 111 KB Posted
- Attached to
- Z1DA--Correct UST Deficiencies 583-23-509 Federal contract opportunity
- Solicitation number
- 36C25023B0050
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for Solicitation # 36C25023B0050 to correct underground storage tank deficiencies at a Veterans Affairs medical center. The form requests a company's North American Industry Classification System code, administrator of its safety and health program, and experience modification rate. It also requires OSHA 300 and 300A forms from the past three years detailing man-hours worked, days away from work cases, restricted activity cases, days away from work rate, and any serious, willful, or repeat OSHA violations along with explanations.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Site Map.pdf | ||
| 36C25023B0050 0001.docx | DOCX document | |
| Attachment II - Limitation on Subcontracting Cert.pdf | ||
| 36C25023B0050_1.docx | DOCX document | |
| Attachment V - RFI Form.pdf | ||
| Attachment III - VHA Directive 1192.01.pdf | ||
| Attachment I - DBA WD.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 # 36C25023B0050.
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 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: __________________________________
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 .