Attachment V - EMR Form.pdf
PDF 182 KB Posted
- Attached to
- Z2DA--Repair and Replace Doors 539-22-202 Federal contract opportunity
- Solicitation number
- 36C25026B0003
About this file
The document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation No. 36C25026B0003. The form requires potential contractors to provide detailed safety and health information, including OSHA 300 Form data for 2022-2024, such as man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations.
The form requests additional details including the North American Industrial Classification System (NAICS) Code (236220), the administrator of the company's Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR). Contractors must attach copies of their OSHA 300 and 300a Forms, which can be accessed through the OSHA publications search page. The form is designed to evaluate a contractor's safety performance and environmental record prior to potential contract award.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Hazardous Material Report.pdf | ||
| 36C25026B0003 0002.docx | DOCX document | |
| 36C25026B0003 0001.docx | DOCX document | |
| Attachment XIII - WD KY20250088.pdf | ||
| Attachmennt XII - NEPA Repair and Replace Doors.pdf | ||
| Attachment X - JCI Sole Source J-A - Redacted.pdf | ||
| Attachment IX - Corbin Russwin J-A - Redacted.pdf | ||
| Attachment XI - PCRA-ICRA.pdf | ||
| Attachment VIII - Best Sole Source J-A Redacted.pdf | ||
| Attachment I - WD OH20250082.pdf | ||
| 36C25026B0003.docx | DOCX document | |
| Attachment VII - VHA Directive 1192.01, Flu.pdf | ||
| Attachment VI - 852.219-75 LOS.docx | DOCX document | |
| Attachment IV - RFI Form.pdf | ||
| Attachment III - Drawings Rev 8-4-25.pdf | ||
| Attachment II - Specifications Rev 8-4-25.pdf |
Show all 16
On GovTribe
Work with this file on GovTribe
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Pre-Award Contractor Safety and Environmental Record
Evaluation Form Information provided below is current and applicable to Solicitation No. 36C25026B0003.
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 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 .