S02_RFP Attachment_EMR.pdf
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- Solicitation number
- 36C24823R0036
About this file
This document contains a pre-award contractor safety and environmental record form and instructions for a federal solicitation to renovate a fire alarm system. The form requests contact information and safety data including total man hours, OSHA recordable incidents, days away from work rates, and serious safety or environmental violations over the past three years. It also requires the contractor's experience modification rating and documentation of OSHA 300 forms. The related solicitation is for renovating the fire alarm system at the James A. Haley VA Medical Center in Tampa, Florida. The solicitation number is 36C24823R0036 and is issued by the Department of Veterans Affairs Veterans Health Administration VISN 8. Contractors must submit the completed safety form to be considered for this opportunity.
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Attachment D
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 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 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): _____________
Please see FOPR 36C24823R0035 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 |
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