Attachment V - EMR.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C25025Q0537
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation #36C25025Q0537, issued by the Department of Veterans Affairs Veterans Health Administration. The form requires contractors to provide detailed safety performance metrics, including OSHA 300 Form data for 2022-2024, such as man-hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and any serious, willful, or repeat OSHA violations.
The solicitation relates to a parking lot and sidewalk repair project (583-25-515) with NAICS code 237310, and mandates contractors to submit comprehensive safety documentation. Specifically, contractors must attach OSHA 300 and 300a Forms, provide their company's Safety and Health Program administrator details, and disclose their Insurance Experience Modification Rate (EMR). The form is designed to evaluate a contractor's safety record and environmental compliance prior to potential contract award.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25025Q0537 0001.docx | DOCX document | |
| RFI Questions and Answers.docx | DOCX document | |
| Attachment VI - RFI Form.docx | DOCX document | |
| Attachment IV - Drawings.pdf | ||
| Attachment III - Specifications.pdf | ||
| 36C25025Q0537_1.docx | DOCX document | |
| Attachment I - WD.pdf | ||
| Attachment II - VHA Directive 1192-01.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 # 36C25025Q0537.
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| CATEGORY |
| 2022 |
| 2023 |
| 2024 |
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 an 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: 237310. |
| 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 .