Contractor Safety and Environmental Record Evaluation Form - Provide Accessibility for AC 17 and 18 Fire Dampers.pdf
PDF 135 KB Posted
- Attached to
- Z2DA--Project 541-21-506 Accessibility for AC 17 & 18 Fire Dampers Fire Dampers VAMC CLEVELAND
- Solicitation number
- 36C25025B0035
About this file
The document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation #36C25025B0035, issued by the Department of Veterans Affairs Veterans Health Administration. The form requires potential contractors to provide detailed safety and environmental performance metrics, including OSHA 300 form data for 2018-2020, covering man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations. Additionally, contractors must submit their NAICS code, identify who administers their Safety and Health Program, and provide their Insurance Experience Modification Rate (EMR). The form is part of a solicitation for Project 541-21-506, which involves accessibility work for AC 17 and 18 Fire Dampers at the Cleveland VAMC, and is designed to assess a contractor's safety performance and environmental record prior to potential contract award.
View the file
Other files
Show all 12
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25025B0035.
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2018 2019 2020 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):
http://www.osha.gov/pls/publications/publication.html
Pre-Award Contractor Safety and Environmental Record Evaluation Form
File details come from the government source that posted it. Updated .