EMR form.pdf
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- Solicitation number
- 36C24922B0008
About this file
This document contains a solicitation for roof replacement services at the James H. Quillen VA Medical Center in Mountain Home, Tennessee. The solicitation is a 100% set-aside for service-disabled veteran-owned small businesses, with a North American Industry Classification System code of 238160 for roofing contractors. Bids are due by February 1, 2022 and the period of performance is 180 calendar days from notice to proceed. The scope of work involves furnishing all labor, materials and equipment to replace the roof on Building 77 in accordance with provided drawings and specifications.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation: 36C24922B0008 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 .