S02 - Attachment 05 - Safety or Environmental Violations and Experience Modification Rate EMR Form (1 page).pdf
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- Attached to
- Z2DA--Install Heat Machine at Main Building Federal contract opportunity
- Solicitation number
- 36C24823R0149
About this file
This document is a pre-award evaluation form for contractor safety records related to the federal contract opportunity to install a heat machine at the main building of the Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8. The form requests information on company safety metrics including number of man hours, OSHA recordable incidents, days away from work rates, and serious violations over the past three years. It also asks for the company's six-digit NAICS code, identification of its safety program administrator, and experience modification insurance rate. Required attachments include the past three years of OSHA Forms 300 and 300a as well as an explanation for any serious violations.
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Text version
Solicitation Attachment
Safety or Environmental Violations and Experience Modification Rate
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 2021 2022
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 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): _____________ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .