EMR FORM.docx
DOCX document 21 KB Posted
- Solicitation number
- 36C24121R0163
About this file
This document contains a pre-award contractor evaluation form and details of a related federal contract opportunity for mental health outpatient renovation work. The form requests safety-related information from offerors including OSHA 300 and 300a forms from the past four years detailing man-hours worked, injuries, and violation history. It also asks for the offeror's NAICS code and information on their safety and health program administration and insurance experience modification rates for the past three years. The related federal contract opportunity is solicitation number 36C24121R0163 from the Department of Veterans Affairs for work on project 52A5-19-305 to renovate an outpatient mental health facility at a Veterans Health Administration location.
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EMR FORM OFFEROR COMPLETE TO SUBMIT WITH PROPOSAL
Pre-Award Contractor Evaluation Form
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2017 |
| 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. (Four serious, one repeat, or one willful disqualifies the contractor.)
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 your 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) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor):
File details come from the government source that posted it. Updated .