Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24921R0159
About this file
This document contains a pre-solicitation notice and contractor evaluation form for a federal design-build renovation project. The Department of Veterans Affairs seeks to renovate Building 207 at the James H. Quillen VA Medical Center in Mountain Home, Tennessee to accommodate a PET-CT clinic. The project will involve demolishing existing finishes and services and modifying exterior and interior spaces. The design-build contractor must provide all labor, materials, and services for the demolition, design, renovation, and construction over a 365-day period. The project cost is estimated between $500,000 and $1 million. The solicitation will be a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses. The pre-award contractor form requests safety, insurance, and financial information to evaluate contractors prior to the October 16, 2021 posting of the solicitation on SAM.gov.
View the file
Other files
Show all 31
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 36C24921R0159
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 .