EXHIBIT C SAFETY.docx
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- Solicitation number
- N62473-25-R-1615
About this file
This is a Safety Data & Narrative form (Exhibit C) for solicitation N62473-25-R-1615 that offerors must complete to provide safety information. The form requires submission of Experience Modification Rate (EMR) and Days Away from Work, Restricted Duty, or Job Transfer (DART) rates for the previous three complete years (2021-2023), along with supporting documentation including OSHA Form 300A. Offerors must explain any EMRs greater than 1.0 and DART rates above 3.0, as well as any upward trends.
The form also requires a two-page maximum Technical Approach for Safety narrative describing the offeror's plans to evaluate and monitor subcontractor safety programs and performance, plus any innovative methods to enhance worksite safety. For joint ventures, each partner must submit safety data, but only one safety narrative is required. The form includes spaces for insurance carrier information and explanations for any missing EMR or DART data. This safety information will be evaluated as part of the technical factors for the water sampling services contract at Marine Corps Air Ground Combat Center, Twentynine Palms.
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Other files
| File | Type | Posted |
|---|---|---|
| N6247325R1615 12.04.2024rev01.pdf | ||
| 2023 Drinking Water Quality Monitoring Plan.pdf | ||
| EXHIBIT A - RFI FORM.docx | DOCX document | |
| EXHIBIT E PPQ.docx | DOCX document | |
| EXHIBIT D.docx | DOCX document | |
| Appointments for the Defense Biometric Identification System.docx | DOCX document | |
| BASE ACCCESS FORM DBIDS Sponsorship Form.pdf | ||
| EXHIBIT B FINANCIAL Q.docx | DOCX document | |
| N6247325R1615 12.04.2024.pdf | ||
| WS J annex MAP INSERT.pdf | ||
| ELIN SCHEDULE PROPOSAL WORKSHEET.xlsx | XLSX spreadsheet | |
| EXHIBIT E EXPERIENCE.docx | DOCX document |
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Text version
EXHIBIT “C”
SAFETY DATA & NARRATIVE
SOLICITATION NO: N62473-25-R-1615
This form is to be completed by the Offeror. Use this form to provide safety information for the Safety factor. EMR and DART rates shall not be submitted for subcontractors.
Joint Venture (JV): Provide a safety Data Sheet for each contractor who is part of the JV; however, only one safety narrative is required.
1. Offeror Name:
Name of Joint Venture partner providing the information below (if applicable):
Offeror’s Three Previous (complete) Years of Reported Safety Data:
Only complete year safety data will be considered. Indicate data rates as decimal figures, not whole numbers
| 2. Experience Modification Rate (EMR) |
| 2021 |
| 2022 |
| 2023 |
3a. Explanation of any extenuating circumstances resulting in any EMRs greater than 1.0 and address any corrective action(s) taken:
3b. Explain any upward EMR trends:
3c. If you do not have an EMR for a given year, state so here and explain why:
4. Insurance Carrier Information:
Insurance Carrier Name:
Agent’s name:
Phone Number:
| 5. U.S. Dept. of Labor, OSHA Days Away from Work, Restricted Duty, or Job Transfer (DART) Rate* |
| 2021 |
| 2022 |
| 2023 |
*For each year, submit a completed copy of U.S. Dept. of Labor, OSHA Form 300A (Summary of Work-Related Injuries and Illnesses), latest version. This information is required regardless of number of employees in the company.
6a. Explain any extenuating circumstances resulting in any DART rates 3.0 or greater and address any corrective action(s) taken:
6b. Explain any upward DART rate trends:
6c. If you do not have a DART rate for a given year, state so here and explain why:
EXHIBIT “C”
SAFETY DATA & NARRATIVE
SOLICITATION NO: N62473-25-R-1615
7. Provide the Technical Approach for Safety using this form. The Technical Approach for Safety Narrative shall not exceed two (2) single-sided pages (or one (1) double-sided page). Any additional pages will not be considered.
Technical Approach for Safety:
7a. Describe the plan the Offeror will implement to evaluate the safety program and performance of potential subcontractors:
7b. Describe the plan to monitor subcontractor worksite safety:
7c. Describe any innovative methods the Offeror will employ that may enhance worksite safety for this procurement:
Note: Form may be expanded.
File details come from the government source that posted it. Updated .