EMR Form.pdf
PDF 232 KB Posted
- Attached to
- Install Fiber Optic Cable FAV PN 564-18-123
- Solicitation number
- 36C25622R0082
About this file
This document contains a pre-award contractor evaluation form and details of a federal contract opportunity for fiber optic cable installation. The pre-award form requests information on the contractor's safety record and insurance rates for the past three years, including OSHA forms and NAICS codes. The federal contract opportunity is solicitation number 36C25622R0082 from the Department of Veterans Affairs for a contractor to remove existing fiber optic and phone cabling from five buildings on site and install new underground fiber optic cabling from the main hospital building to include conduit, duct bank, cable and associated components in accordance with state and federal requirements, industry standards, and codes. The work must comply with all OSHA regulations.
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Text version
EMR FORM
FORM FOR BIDDER/OFFEROR TO
COMPLETE & SUBMIT WITH PROPOSAL
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): _____________
Pre-Award Contractor Evaluation Form
Company Name: ______________________________________________ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .