EMR Form.pdf
PDF 141 KB Posted
- Attached to
- Z1DA--Project 621-22-119, Repair Bldg 8 Slate Roof Project 621-22-111, Repair Bldg 69 Slate Roof
- Solicitation number
- 36C24922B0007
About this file
This document provides details for two federal construction contract opportunities issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The solicitations are for roof repair projects at Building 69 and Building 8 at the James H. Quillen VA Medical Center in Mountain Home, Tennessee. The NAICS code for this acquisition is 238160. The opportunities are set aside 100% for SDVOSB contractors. Bids are due on February 1, 2022. The period of performance for Building 69 is 120 days and 45 days for Building 8 from notice to proceed. The scope of work involves furnishing all labor, materials and equipment to complete slate roof repairs in accordance with provided drawings and specifications.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation: 36C24922B0007 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): ____________________________
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .