EMR Attachement.pdf
PDF 476 KB Posted
- Attached to
- Replace Subbasement Storm Sewer Connection - 610A4-24-502 Federal contract opportunity
- Solicitation number
- 36C25024B0023
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity to replace a storm sewer connection.
The evaluation form requests contact information and safety data from the past three years, including man hours, OSHA recordable incidents, rates of days away from work, and any serious violations. It also asks for the company's NAICS code, safety program administrator, and experience modification rate.
The federal contract opportunity is solicited by the Department of Veterans Affairs to replace the storm sewer connection in the subbasement of a VA facility. The contractor must provide all labor, materials, equipment, project management, quality assurance and other resources needed to complete the work, which is necessary due to multiple cracks and openings from corrosion in the current connection.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| VHA Directive 1192.01 (002).pdf | ||
| RFI Attachment.pdf | ||
| Davis-Bacon Act WD IN20230002.pdf | ||
| Attachment IV - Limitation on Subcontracting Cert.pdf | ||
| 6a - Storm Sewer Site Drawing.pdf | ||
| Picture of Subbasement Storm Sewer Connection.jpeg | JPEG file | |
| 36C25024B0023.pdf | ||
| 5 - Specifications.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation # 36C25024B0023
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 2021 2022
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 .