S02_Attachment EMR (1 Page).pdf
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- Solicitation number
- 36C24823R0153
About this file
This document contains an attachment for a federal solicitation to renovate and abate flooring in three buildings at the Bay Pines VA Medical Center. The attachment requests safety and environmental compliance information from prospective contractors, including OSHA 300 and 300A forms for the previous three years documenting man-hours, injury rates, and any serious violations. It also requires the contactor's experience modification rate for insurance over the same period, not to exceed 1. The solicitation is identified as number 36C24823R0153 and is issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8. Contractors must complete the form and submit the requested documentation to be considered for the award to renovate flooring at the specified VA medical facility location.
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Attachment
Safety or Environmental Violations and Experience Modification Rate
Pre-Award Contractor Safety and Environmental Record Form
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2021 2022 2023
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 or any EPA violations 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. Who administers your company’s Safety and Health Program?
3. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of 1 or less is required): _____________ http://www.osha.gov/pls/publications/publication.html
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
| Solicitation Attachment |
| Safety or Environmental Violations and Experience Modification Rate |
File details come from the government source that posted it. Updated .