Contractor EMR Certification Form.pdf
PDF 141 KB Posted
- Solicitation number
- 36C24921B0012
About this file
This document includes a pre-solicitation notice and evaluation form for a construction renovation project. The Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9 will renovate Building 8 at the James H. Quillen VA Medical Center in Mountain Home, Tennessee. The project value is estimated between $500,000 and $1,000,000, and it is a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses. Interested contractors must complete the attached evaluation form providing safety records and insurance information by the specified dates. Responses are due between August 23, 2021 and September 23, 2021. Eligible contractors must be verified in the Center for Verification and Evaluation database and have an active System for Award Management listing. The awarded contractor must also enroll in VETS4212. The project number is 36C24921B0012.
View the file
Other files
Show all 30
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24921B0012
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 .