EMR 36C25024B0003.docx
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- Solicitation number
- 36C25024B0003
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and details of a related federal contract opportunity for upgrade signage and wayfinding at a Veterans Affairs medical center. The evaluation form requests information on the contractor's OSHA 300 forms from the past three years including man hours, cases involving days away from work or restricted activity, days away restricted or transferred rate, and any serious, willful, or repeat OSHA violations. It also asks for the contractor's NAICS code, who administers their safety program, and insurance experience modification rate. The related federal contract opportunity is solicitation number 36C25024B0003 to replace exterior and interior signs, repair landscaping as needed, and install banners at the Veterans Affairs Medical Center in Fort Wayne, Indiana, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form Information provided below is current and applicable to Solicitation # 36C25024B0003.
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2022 |
| 2021 |
| 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): ____________________________ |
File details come from the government source that posted it. Updated .