S02_RFP EMR.pdf
PDF 309 KB Posted
- Solicitation number
- 36C24823R0189
About this file
This document contains an attachment for a solicitation requesting safety and environmental record information from prospective contractors. The attachment requests companies to provide details of their OSHA 300 forms from 2019 to 2021 including number of man hours, days away from work cases, and DART rates. It also asks for any serious, willful, or repeat OSHA or EPA violations in the past three years along with an explanation and copies of the OSHA 300 and 300a forms. Additional questions inquire about who administers the company's safety and health program and the experience modification rates for insurance over the past three years. The related federal contract opportunity is for installing new x-ray equipment at room 2A168 of building B-100 for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8.
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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 |
File details come from the government source that posted it. Updated .