Attch VI - EMR.docx
DOCX document 15 KB Posted
- Attached to
- Z1DA--Install Card Readers 539-25-502
- Solicitation number
- 36C25025Q0476
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation #36C25025Q0476, issued by the Department of Veterans Affairs Veterans Health Administration. The form requires potential contractors to provide detailed safety and performance metrics, including OSHA 300 Form data for 2022-2024, such as man-hours, workplace injury cases, days away/restricted work rates, and OSHA violation history.
The form requests specific documentation, including OSHA 300 and 300a Forms, and asks contractors to provide their six-digit NAICS code (236220), identify who administers their Safety and Health Program, and disclose their Company's Insurance Experience Modification Rate (EMR). The solicitation appears to be related to a project involving the installation of card readers, though specific project details are not elaborated in this safety evaluation document.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25025Q0476 0003.docx | DOCX document | |
| 36C25025Q0476 0002.docx | DOCX document | |
| 36C25025Q0476 0001.docx | DOCX document | |
| Attch V - JCI J-A Redacted.pdf | ||
| Attch VII - RFI Form.pdf | ||
| Attch IV - 539-25-502 Install Card Reader Drawings.pdf | ||
| Attch I - Wage Determinations - Cincy.pdf | ||
| Attch II - Wage Determinations - Ft. Thomas.pdf | ||
| Attch III - 539-25-502 Specifications.pdf | ||
| Attch VIII - VHA Directive 1192.01, Seasonal Influen..pdf | ||
| 36C25025Q0476.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25025Q0476.
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| CATEGORY |
| 2022 |
| 2023 |
| 2024 |
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 an 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): ____________________________ |
File details come from the government source that posted it. Updated .