Attachment V EMR Form.pdf
PDF 159 KB Posted
- Attached to
- Z1DA--Repair T5 Transformer 539-25-503
- Solicitation number
- 36C25025B0043
About this file
The document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation No. 36C25026B0001. The form requires potential contractors to provide detailed safety performance information, including OSHA-related data for 2022-2024. Contractors must complete sections on man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rate, and OSHA violations, and attach OSHA 300 and 300a Forms. Additional required information includes the six-digit NAICS Code (236220), the administrator of the company's Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR).
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Other files
| File | Type | Posted |
|---|---|---|
| signin 2.jpg | JPG image | |
| Arc Flash Study - T5.pdf | ||
| Transformer Measurements.docx | DOCX document | |
| signin 1.jpg | JPG image | |
| 36C25025B0043 0002.pdf | ||
| Siemens Panel TR MAIN FDS.pdf | ||
| Bid RFIs.docx | DOCX document | |
| 36C25025B0043 0001.pdf | ||
| 36C25025B0043_1posted.pdf | ||
| Attachment II 539-25-503 Repair Transformer Specs.pdf | ||
| Attachment III 539-25-503 Repair T5 Transformer Dwgs.pdf | ||
| Attachment VII VHA Directive 1192.01, Flu.pdf | ||
| Attachment I WD 10.21.2025.pdf | ||
| Attachment IV RFI Form.pdf | ||
| Attachment VI 852.219-75 LOS.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. 36C25026B0001.
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 .