S02 - Attachment 4 - EMR.docx
DOCX document 14 KB Posted
- Attached to
- Replace Lake Baldwin DOM Hot Water Heater Federal contract opportunity
- Solicitation number
- 36C24823R0131
About this file
This document contains a pre-award evaluation form and details for a federal contract opportunity to replace a water heater system. The form requests company information including North American Industry Classification System code, OSHA recordable incident rates for the past three years with supporting documentation, insurance experience modification rate for the past three years, and identification of the safety program administrator. The related federal contract opportunity is to assess, design, and replace the existing hot water heater system at the Lake Baldwin Domiciliary Building 520 for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8. The work includes general construction, alterations, and mechanical, electrical, plumbing and civil/structural work as described in the specifications and drawings.
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Text version
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 .