Attachment VI - EMR Certification Form 610-20-201.docx
DOCX document 17 KB Posted
- Attached to
- P500--Demolish Building 50 610-20-201
- Solicitation number
- 36C25022B0018
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity for demolition services. The evaluation form requests a contractor's OSHA 300 forms from 2016 to 2019, North American Industry Classification code, details on the company's safety and health program administrator, and experience modification rate. The related federal contract opportunity is solicitation number 36C25022B0018 for demolishing Building 50 at the VA Northern Indiana Health Care System campus in Marion, Indiana. The statement of work involves asbestos and equipment abatement, foundation and structure removal, and site work including asphalt, curbs, and signage installation. The project must be completed within 130 calendar days of the notice to proceed. The contracting agency is the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25022B0018 0005.pdf | ||
| 36C25022B0018 0004.pdf | ||
| 36C25022B0018 0003.pdf | ||
| 36C25022B0018 0002.pdf | ||
| Roster Site Visit -2.pdf | ||
| Roster Site Visit -1.pdf | ||
| Attachment I - RFI Form.doc | DOC document | |
| 36C25022B0018 0001 (1).pdf | ||
| Attachment V - Flu Directive.pdf | ||
| Attachment II - Specifications.pdf | ||
| 36C25022B0018_1.docx | DOCX document | |
| Attachment III - Drawings.pdf | ||
| Attachment I - RFI Form.doc | DOC document | |
| Attachment IV - Wage Determination.pdf |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Project 583-19-203:
Company Name: Address: Telephone: Fax: Email: Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2016 |
| 2017 |
| 2018 |
| 2019 |
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: 238910
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 .