Attachment IV - EMR Form.pdf
PDF 111 KB Posted
- Solicitation number
- 36C25024B0062
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form related to Solicitation No. 36C25024B0062, which is for Structural Repairs to Underground Parking Garage - 583-20-103 issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10.
The form requires the contractor to provide information on their company's OSHA 300 forms, including number of man hours, cases involving days away from work, restricted activity, or both, and days away, restricted, or transferred rate. The contractor must also disclose any serious, willful, or repeat OSHA violations within the last 3 years. Additionally, the contractor must provide their 6-digit NAICS code, who administers their safety and health program, and their Insurance Experience Modification Rate (EMR). This information is required as part of the pre-award evaluation for the solicitation.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25024B0062 0006.docx | DOCX document | |
| Attachment I - Specifications Revised II.pdf | ||
| Attachment II - Drawings Revised II.pdf | ||
| 36C25024B0062 0005.docx | DOCX document | |
| Attachment I - Specifications Revised.pdf | ||
| Attachment II - Drawings Revised.pdf | ||
| 36C25024B0062 0004.docx | DOCX document | |
| 36C25024B0062 0003.docx | DOCX document | |
| 36C25024B0062 0002.docx | DOCX document | |
| Attachment III - Detail 8 - S-504 REV01.pdf | ||
| Attachment II - Site Visit Sign-In Sheet.pdf | ||
| Attachment I - Questions and Answers.pdf | ||
| Attachment IV - Scabble Elevation Sketch.pdf | ||
| 36C25024B0062 0001.docx | DOCX document | |
| Attachment V - Detail 2 and 2A - S-504 REV01.pdf | ||
| Attachment III - DBA WD.pdf | ||
| Attachment I - Specifications.pdf | ||
| Attachment V - RFI Form.pdf | ||
| Attachment II - Drawings.pdf | ||
| 36C25024B0062_1.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record
Evaluation Form Information provided below is current and applicable to Solicitation No. 36C25024B0062.
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2021 2022 2023
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 .