ContractorEMR_Certification.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24922B0027
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity for renovating VAV controls at a Veterans Affairs medical facility. The evaluation form requests the contractor's OSHA 300 and 300a forms from the past three years, North American Industry Classification System code, details on workplace injuries and incidents, and who administers its safety and health program. It also asks for the company's insurance experience modification rate. The related federal contract opportunity is a solicitation from the Department of Veterans Affairs to renovate VAV controls in several buildings at a Veterans Integrated Service Network facility for an unspecified award date.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24922B0027
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2019 |
| 2020 |
| 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: 238220
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 .