Attachment - V - Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Solicitation number
- 36C25021B0042
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity from the Department of Veterans Affairs. The form requests safety-related information from 2017 to 2020, including total man hours, OSHA-recordable incidents, days away from work rates, and serious violations. It also asks for the company's NAICS code and who administers its safety program. Additionally, it requests the company's insurance experience modification rate. The related federal contract opportunity is solicitation number 36C25021B0042 to upgrade elevators in buildings 138, 172, and 174. No other details are provided on the opportunity requirements or terms.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C25021B0042:
Company Name: Address: Telephone: Fax: Email: Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2017 |
| 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:
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate (EMR):
File details come from the government source that posted it. Updated .