S02 - Attachment 6 - Contractor Safety and Environmental Record Evaluation Form.pdf
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- Solicitation number
- 36C24924R0024
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for the solicitation to upgrade elevators in three buildings at a Veterans Affairs medical center. The form requests the contractor's company information, OSHA 300 and 300a forms from the past three years detailing man-hours worked, injuries reported, and any serious violations incurred. It also asks for the contractor's NAICS code of 236220 for commercial and institutional building construction and who administers its safety and health program. The contractor must provide its current experience modification rate to be considered for the award under solicitation number 36C24924R0024 by the Department of Veterans Affairs Veterans Health Administration VISN 9 for the elevator upgrade project at buildings 1, 1A, and 7.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24924R0024
Company Name:
Address:
Telephone:
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 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 .