Attachment IV - EMR Form.pdf
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- Solicitation number
- 36C25023B0054
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for a bathroom deficiency remediation project being conducted by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10. The form requests contact information for the bidding company and data from their OSHA 300 forms for the last three years, including total man hours, cases involving days away from work or restricted activity, days away from work rate, and any serious, willful, or repeat OSHA violations. It also asks for the company's six-digit NAICS code, who administers their safety and health program, and their insurance experience modification rate. Copies of the company's OSHA 300 and 300a forms from the last three years must be attached.
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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 .