Attachment VI - EMR Form.pdf
PDF 111 KB Posted
- Solicitation number
- 36C25023B0065
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for a federal solicitation. The form requests information on the contractor's OSHA 300 forms from the past three years including man hours, cases involving days away from work or restricted activity, and days away restricted or transferred rate. It also asks for details on any serious, willful, or repeat OSHA violations and requires attaching copies of OSHA 300 and 300a forms. The contractor must provide its six-digit NAICS code for the acquisition and identify who administers its safety and health program as well as its insurance experience modification rate. The related federal contract opportunity is for project 539-19-101 to reconfigure primary care to the Patient Aligned Care Team model from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25023B0065 0001.docx | DOCX document | |
| 36C25023B0065_1.docx | DOCX document | |
| Attachment I - DBA WD.pdf | ||
| Attachment III - Drawings.pdf | ||
| Attachment VIII - Justifications and Approvals.pdf | ||
| Attachment VII - RFI Form.pdf | ||
| Attachment IV - VHA Directive 1192.01.pdf | ||
| Attachment V - Limitation on Subcontracting Cert.pdf | ||
| Attachment II - Specs.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 # 36C25023B0065.
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 2021 2022
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 .