EMR.pdf
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- Solicitation number
- 36C24822R0173
About this file
This document contains an attachment to a federal solicitation requesting safety and environmental records from prospective contractors. The solicitation seeks to replace the Cath Lab 1 facility at the James A. Haley VA Medical Center in Tampa, Florida. Offerors must submit their OSHA 300 and 300A forms from the past three years along with explanations for any serious, willful, or repeat violations. They must also provide their company's experience modification rates over the same period, with a rate of 1.0 or below required. The contact administering the company's safety and health program must be identified. This attachment collects safety and environmental performance history to evaluate contractors for this project to replace the Cath Lab facility at the Tampa VA Medical Center.
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Attachment D
Safety or Environmental Violations and Experience Modification Rate
Pre-Award Contractor Safety and Environmental Record Form
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 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 or any EPA violations 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. Who administers your company’s Safety and Health Program?
3. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of 1 or less is required): _____________
Please see FOPR 36C24822R0173 http://www.osha.gov/pls/publications/publication.html
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
File details come from the government source that posted it. Updated .