EMR Attachment - Template.docx
DOCX document 15 KB Posted
- Attached to
- Project 757-23-101 Air Cooled Chillers
- Solicitation number
- 36C25025R0096_1Amend01
About this file
The file is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for a federal solicitation (36C25021B0075). The document requires potential contractors to provide detailed safety performance metrics, including OSHA 300 Form data for 2018-2020, covering man hours, workplace injury cases, DART (Days Away, Restricted, or Transferred) rates, and OSHA violations. Contractors must attach OSHA 300 and 300a Forms, specify their six-digit NAICS Code, identify the administrator of their Safety and Health Program, and disclose their Insurance Experience Modification Rate (EMR).
The related federal contract opportunity is a solicitation (36C25025R0096_1Amend01) for Project 757-23-101 Air Cooled Chillers, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10. The amendment's primary purpose is to post Request for Information Questions and Answers, with the proposal due date remaining August 11, 2025, at 2:30 PM EST. All other terms and conditions of the original solicitation remain unchanged.
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Other files
| File | Type | Posted |
|---|---|---|
| S02. 36C25025R0096_1- Amend0001.pdf | ||
| S05. Request For Information - Question and Answers.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 # 36C25021B0075.
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2018 |
| 2019 |
| 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 .