Attachment VIIII - EMR.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C24726Q0685
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form required for Solicitation #36C24726R0074, related to a Veterans Affairs RFQ for B7 HVAC & Electrical Upgrade Construction (Solicitation #36C24726Q0685). The form is an appendix that serves as a template for contractors to submit safety and environmental compliance documentation as a pre-award requirement.
Contractors must complete the form by providing company identification information and detailed occupational safety data for the three-year period covering 2023, 2024, and 2025. Required safety metrics include total man-hours (jobsite and office), number of OSHA recordable cases involving days away from work or restricted activity (DART cases), calculated DART rates, and documentation of serious, willful, or repeat OSHA violations from the preceding three years with explanations. Contractors must submit copies of OSHA 300 and 300a Forms, provide their six-digit NAICS code, identify the company administrator responsible for the Safety and Health Program, and report their Experience Modification Rate (EMR) from their workers' compensation insurance. This evaluation assesses contractor safety performance and risk profile prior to contract award.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form Information provided below is current and applicable to Solicitation #36C24726R0074 Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2023 |
| 2024 |
| 2025 |
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 .