EMR 1 page.pdf
PDF 267 KB Posted
- Solicitation number
- 36C24825R0112
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Form, designed to collect comprehensive safety and environmental performance data from potential contractors. The form requires companies to provide detailed information across three years (2022-2024), including total man-hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and any serious, willful, or repeat OSHA or EPA violations. Companies must also attach their OSHA 300 and 300a forms, identify who administers their Safety and Health Program, and provide their Insurance Experience Modification Rate (EMR), with a requirement that the EMR be 1.0 or less.
The form is part of a VA solicitation (Solicitation Number: 36C24825R0112) for renovating pharmacy hood ductwork at the James A. Haley VA Hospital in Tampa, FL, with a project value between $250,000 and $500,000. The solicitation is exclusively set aside for Service-Disabled Veteran-Owned Small Businesses (SDVOSB), with contractors required to perform at least 25% of the contract work with their own employees. Key submission requirements include a detailed safety record, bid bond, project schedule, past performance documentation, and a separate price proposal, with proposals due by the specified deadline and a planned site visit on 06/25/2025.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C24825R0112 0002.pdf | ||
| 36C24825R0112 0001.docx | DOCX document | |
| WD FL20250208 05232025.pdf | ||
| P01_673-23-115-Bid Documents - Maps.pdf | ||
| 36C24825R0112_1.docx | DOCX document | |
| 07- 673-23-115 Specifications update.pdf | ||
| Base Offer Price Breakdown - 1 page.xlsx | XLSX spreadsheet | |
| Past Performance Questionnaire - 4 Pages.docx | DOCX document |
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
Attachment
Safety or Environmental Violations and Experience Modification Rate
Pre-Award Contractor Safety and Environmental Record Form
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 or any EPA violations 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. Who administers your company’s Safety and Health Program?
3. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of 1 or less is required): _____________ http://www.osha.gov/pls/publications/publication.html
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
File details come from the government source that posted it. Updated .