S02-Contractor EMR Certification Form - 36C24921B0014.docx
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- Attached to
- Z2DZ-36C249-21-AP-3182 - 621-15-101 - Correct Admin Bldg. -20 Environment & Condition Deficiencies
- Solicitation number
- 36C24921B0014
About this file
This document contains a pre-solicitation notice for a federal contract opportunity to correct administration building deficiencies at a VA medical center. The contract is estimated between $1,000,000 and $5,000,000 and will be awarded through sealed bidding procedures. The solicitation is expected to be issued on October 20, 2021 and close on November 20, 2021. This is a 100% set-aside for Service-Disabled Veteran Owned Small Businesses. Only SDVOSBs verified in the CVE database and registered in SAM will be considered. In addition to solicitation requirements, offerors must demonstrate responsibility in accordance with FAR Part 9. Questions must be submitted in writing to the named Contract Specialist by the solicitation release date.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation:
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): ____________________________
File details come from the government source that posted it. Updated .