Attachment X - EMR.docx
DOCX document 15 KB Posted
- Attached to
- Z1DA--Improve Sewer System and Water Loop 610-21-104 Federal contract opportunity
- Solicitation number
- 36C25025B0007
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form that must be completed by contractors bidding on VA Solicitation #36C25025B0007 for improving sewer systems and water loop projects. The form requires contractors to provide three years of safety statistics (2021-2023) from their OSHA 300 Forms, including man-hours worked, cases involving days away from work or restricted activity, DART rates, and any OSHA violations. Contractors must also submit their NAICS code, safety program administrator information, and Insurance Experience Modification Rate (EMR). The form requires attachment of OSHA 300 and 300a Forms and explanations for any serious, willful, or repeat OSHA violations from the past three years.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form Information provided below is current and applicable to Solicitation # 36C25025B0007.
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2023 |
| 2022 |
| 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 .