EMR.pdf
PDF 546 KB Posted
- Solicitation number
- 36C24924R0083
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for solicitation 36C24924R0083, used to assess potential contractors' safety and environmental performance records. The form requires contractors to provide three years (2021-2023) of safety statistics using OSHA 300 Forms, including total man-hours worked, cases involving days away from work or restricted activity, DART rates, and any serious OSHA violations.
The form requests company identification details and requires contractors to submit OSHA 300 and 300a Forms, specify their six-digit NAICS code, identify who administers their Safety and Health Program, and provide their Insurance Experience Modification Rate (EMR). This evaluation form is part of a Department of Veterans Affairs solicitation for Project 621-22-107 to modernize Building-108 Boiler Plant and Systems.
View the file
Other files
Show all 16
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form 36C24924R0083
Information provided below is current and applicable to Solicitation:
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2021 2022 2023
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 .