Attachment VIII - EMR Form.pdf
PDF 112 KB Posted
- Attached to
- Z2NB--Project No. 539-20-101 - Replace Fort Thomas Boilers. Federal contract opportunity
- Solicitation number
- 36C25024B0075
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form associated with Solicitation No. 36C25024B0075 for Project No. 539-20-101 - Replace Fort Thomas Boilers, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10.
The form requires the contractor to provide information related to its OSHA 300 forms, including number of man-hours, number of cases involving days away from work, its DART rate, and any OSHA violations in the last 3 years. The contractor must also provide its 6-digit NAICS code, who administers the company's safety and health program, and its Insurance Experience Modification Rate (EMR). The contractor must attach copies of the OSHA 300 and 300a forms. This information is being collected as part of the pre-award evaluation of the contractor's safety and environmental record.
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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. 36C25024B0075.
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2021 2022 2023
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: 238220
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 .