Attachment V - EMR Attachment.pdf
PDF 111 KB Posted
- Solicitation number
- 36C25022B0045
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and details of a related federal contract opportunity for replacing domestic water and chilled drinking water piping at a Department of Veterans Affairs facility. The evaluation form requests safety-related information such as company name and address, total man hours, OSHA recordable incidents, days away from work rates, and insurance modification rates. It also asks for NAICS codes and safety program administration details. The related federal opportunity is solicited under solicitation number 36C25022B0045 to replace domestic water and chilled drinking water piping as project number 539-21-102 through the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25022B0045 0002.docx | DOCX document | |
| Replace Domestic Water and Chilled Drinking Water Piping - Bid Narrative.pdf | ||
| AWWA C651.pdf | ||
| 36C25022B0045 0001.docx | DOCX document | |
| Attachment III - DBA WD.pdf | ||
| Attachment VI - RFI Attachment.pdf | ||
| Attachment IV - Limitations on Subcontracting_Certificate of Compliance.pdf | ||
| Attachment I - Drawings.pdf | ||
| 36C25022B0045_1.docx | DOCX document | |
| Attachment II - Specifications.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 # 36C25022B0045.
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2019 2020 2021
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 .