S02_RFP Attachment_EMR.pdf
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- Attached to
- Z1DA--FY23 NRM-Tier 1 (PROJ 673-22-109) D/B: Install Fan Array in AHU OR2-7 and Replace Exhaust Fans
- Solicitation number
- 36C24823R0068
About this file
This document contains an attachment to a solicitation for installation services. The attachment requests safety and environmental record information from offerors, including OSHA 300 and 300A forms for the past three years with data on man-hours worked, days away from work cases, and DART rates. It also requests information on any OSHA or EPA violations along with an insurance experience modification rate of 1.0 or less for the past three years. The related federal contract opportunity is solicitation number 36C24823R0068 from the Department of Veterans Affairs for installing a fan array in an air handling unit and replacing exhaust fans at the James A. Haley Veterans Medical Center in Tampa, Florida. The point of contact listed is amy.shaw3@va.gov.
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Text version
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 |
File details come from the government source that posted it. Updated .