EMR 1 page.pdf
PDF 267 KB Posted
- Solicitation number
- 36C24825R0116
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Form designed to capture a company's safety performance metrics for a federal contract opportunity. The form requires detailed information about workplace safety, including man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and any serious OSHA or EPA violations over the past three years. Companies must provide their OSHA 300 and 300a Forms, identify who administers their Safety and Health Program, and disclose their Insurance Experience Modification Rate (EMR), which must be 1.0 or less to be considered for the contract. The form is specifically associated with a Department of Veterans Affairs solicitation (Solicitation Number: 36C24825R0116) for a BB Upgrade Building One Sanitary Riser project at the James A. Haley VA Hospital in Tampa, FL, with a project value between $1,000,000 and $2,000,000.
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Other files
| File | Type | Posted |
|---|---|---|
| RFI_BB Sanitary Riser-Responses.docx | DOCX document | |
| 36C24825R0116 0002.docx | DOCX document | |
| 36C24825R0116 0001.docx | DOCX document | |
| 673-21-154-Bid-CD Drawings_Stamped-TMM2211.pdf | ||
| 36C24825R0116_1.docx | DOCX document | |
| Past Performance Questionnaire - 4 Pages.docx | DOCX document | |
| WD FL20250208 05232025.pdf | ||
| Base Offer Price Breakdown - 1 page.xlsx | XLSX spreadsheet | |
| 7b Vol2 Specifications.pdf | ||
| 7a Vol1 Specifications.pdf | ||
| 7 Drawings.pdf |
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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 .