S02 - Attachment 03 EMR (MANDATORY) (1 Page).pdf

PDF 152 KB Posted

Attached to
Z2DA--Replace CLC Building Grease Trap Federal contract opportunity
Solicitation number
36C24823R0020
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8

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ATTACHMENT: 3

EMR FORM FOR BIDDER/OFFEROR TO COMPLETE & 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 2019 2020 2021 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 .