EMR Attachment.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C25022B0038
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25022B0038 0001.docx | DOCX document | |
| 610-21-517 - 22-102m - 2 of 7 revision 1.pdf | ||
| RFI Form.docx | DOCX document | |
| 36C25022B0038.docx | DOCX document | |
| Wage determination dtd June 2022.txt | TXT text file | |
| 610-21-517 asphalt sealcoating - drawings.pdf | ||
| 610-21-517 asphalt sealcoating - specifications.pdf |
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Pre-Award Contractor Safety and Environmental Record Evaluation Form Information provided below is current and applicable to Solicitation 36C25022B0038 for the Provide Asphalt Sealcoating and Line Stripping – 610-21-517 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): ____________________________ |
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