Attachment IV - EMR Form.pdf
PDF 154 KB Posted
- Attached to
- Z2DA--Project No. 539-CSI-207 - Prepare Site for MRI. Federal contract opportunity
- Solicitation number
- 36C25024B0100
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form related to Solicitation No. 36C25024B0100 for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10. The form requires the contractor to provide information about their safety record, including the number of man-hours, OSHA recordable incidents, and any OSHA violations over the last 3 years. The contractor must also provide their North American Industry Classification System (NAICS) code and Insurance Experience Modification Rate (EMR). This information is used to evaluate the contractor's safety and environmental compliance prior to award of the contract.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25024B0100 0005.docx | DOCX document | |
| Addendum 1.pdf | ||
| 36C25024B0100 0004.docx | DOCX document | |
| 36C25024B0100 0003.docx | DOCX document | |
| 36C25024B0100 0002.docx | DOCX document | |
| 36C25024B0100 0001.docx | DOCX document | |
| Attachment III - Drawings.pdf | ||
| Attachment II - Specs.pdf | ||
| Attachment I - DBA WD.pdf | ||
| 36C25024B0100_1.docx | DOCX document | |
| Attachment V- RFI Form.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 No. 36C25024B0100.
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 .