Attachment - VIII - Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Attached to
- Y1NE--Upgrade Reverse Osmosis Processes / Sterilization 583-22-201 Federal contract opportunity
- Solicitation number
- 36C25022B0006
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and details of a related federal contract opportunity for upgrading reverse osmosis processes and sterilization. The evaluation form requests contact information and safety data including OSHA 300 and 300a forms, NAICS code, and insurance experience modification rate from prospective contractors. The related federal contract opportunity is solicitation number 36C25022B0006 issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10 for upgrading reverse osmosis processes and sterilization systems. Contractors are required to submit the completed evaluation form and supporting safety documents to be considered for this opportunity.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| RFI Responses.pdf | ||
| 36C25022B0006 0001.docx | DOCX document | |
| Attachment - IX - RFI Form Solicitaton.docx | DOCX document | |
| Attachment - IV - Reverse Osmosis Site Plan Layout Drawing.pdf | ||
| Attachment - I - ABSO Foot Print Drawing.pdf | ||
| Attachment - VI - VA Final Rinse Water Usage Chart.pdf | ||
| Attachment - VII - Wage Determination.pdf | ||
| Attachment - III - Reverse Osmosis Equipment Drawing.pdf | ||
| Attachment - II - Basement Plumbing Plan Drawing.zip | ZIP file | |
| 36C25022B0006.docx | DOCX document | |
| Attachment - V - Reverse Osmosis Workspace Drawing.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 36C25022B0006:
Company Name: Address: Telephone: Fax: Email: Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2018 |
| 2019 |
| 2020 |
| 2021 |
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:
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 .