S02-Attachment 6-Contractor Safety and Environmental Record Evaluation Form 626A4-21-101.pdf
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- Solicitation number
- 36C24922R0091
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for a federal solicitation to renovate and expand a medical facility. The form requests information on the contractor's man hours, OSHA recordable incidents, days away from work rates, OSHA violations in the past three years, copies of the contractor's OSHA forms, the contractor's NAICS code of 236220 for commercial and institutional building construction, the administrator of the contractor's safety and health program, and the contractor's insurance experience modification rate. The related federal contract opportunity is solicitation number 36C24922R0091 to renovate and expand the PMRS facility at the Tennessee Valley Healthcare System for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24922R0091
Company Name:
Address:
Telephone:
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.
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 six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 236220 – Commercial and Institutional Building Construction
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 .