EMR Attachment.docx
DOCX document 14 KB Posted
- Attached to
- Z2LB--Repair Roads 610-21-210
- Solicitation number
- 36C25022B0040
About this file
This document contains a pre-award evaluation form and related federal contract opportunity for road repair services at a Veterans Affairs medical center. The pre-award form requests safety and environmental records from the past three years, including OSHA forms, accident rates, violations, and insurance modification rates. The federal opportunity is a 100% set-aside for service-disabled veteran-owned small businesses to repair roads at the Northern Indiana VA Medical Center for $500,000 to $1,000,000. The period of performance is 176 calendar days from notice to proceed. Bids are due by May 2022. Submitted documents must include forms SF-1442, SF-24, and completed representations. All contractor employees must complete privacy and environmental training, screening for COVID-19 and influenza vaccination.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25022B0040 0003.docx | DOCX document | |
| 36C25022B0040 0002.docx | DOCX document | |
| 36C25022B0040 0001.docx | DOCX document | |
| VAAR 852 219 77.docx | DOCX document | |
| 610-21-210 Specifications.pdf | ||
| 610-21-210 Complete Drawing Set.pdf | ||
| RFI Form.docx | DOCX document | |
| 36C25022B0040_1.docx | DOCX document | |
| VHA Directive 1192 01.pdf | ||
| Wage Determination.pdf |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form Information provided below is current and applicable to Solicitation 36C25022B0040 for the Repair Roads 610-21-210 project:
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2018 |
| 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: __________________________________ |
| 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 .