Contractor EMR Certification Form.pdf
PDF 142 KB Posted
- Solicitation number
- 36C24921B0008
About this file
This document includes a pre-solicitation notice and contractor evaluation form for a federal construction project. The Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9 is seeking to renovate existing space adjacent to the emergency department at the James H. Quillen VA Medical Center in Mountain Home, Tennessee into new radiology, police holding, and administrative areas to serve the existing emergency department. The project is estimated to cost between $5 million and $10 million. The pre-solicitation notice specifies this will be a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses under NAICS code 236220 with a size standard of $39.5 million. The solicitation is expected to post on May 25, 2021 and close on June 24, 2021. The accompanying contractor evaluation form requests safety and insurance information to determine a contractor's responsibility prior to award.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24921B0008 0002.pdf | ||
| 081710_Add1.pdf | ||
| 000110_Add1.pdf | ||
| Amendment 0001.pdf | ||
| 087100_Add1.pdf | ||
| 013323.1 Master Submittal List_Add1.pdf | ||
| Revised drawings 6-21-2021.pdf | ||
| 010000_Add1.pdf | ||
| 224000 Add1.pdf | ||
| 099659_Add1.pdf | ||
| Amendment Summary.pdf | ||
| Pre bid sign in sheet.pdf | ||
| RFI Form - Expand Emergency Dept.pdf | ||
| Mt Home ED Final CD Specs_Revised 210512.pdf | ||
| WD TN20210111 1-1-2021.pdf | ||
| Mt Home ED Final CD Drawings _Revised 210512.pdf | ||
| 36C24921B0008_1.pdf | ||
| 36C24921B0008.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24921B0008
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2018 2019 2020
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: __________________________________
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 .