Contractor EMR Certification Form.pdf
PDF 141 KB Posted
- Attached to
- Y1DZ--621-22-106 - Construct Containment Segregated Compounding Area (C-CSCA) Federal contract opportunity
- Solicitation number
- 36C24922B0009
About this file
This document contains a pre-solicitation notice and evaluation form for a federal construction contract. The Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9 is seeking a contractor to completely prepare a site for building operations, including demolition and removal of existing structures, and furnish labor and materials to construct a new Containment Segregated Compounding Area and associated spaces at the James H. Quillen VA Medical Center in Mountain Home, Tennessee. The estimated value of the construction is between $500,000 and $1,000,000. The NAICS code for this requirement is 236220. This opportunity is open only to verified Service-Disabled Veteran Owned Small Businesses and is set aside 100% for SDVOSBs. The solicitation is expected to be released on or around December 28, 2021, with proposals due on or around January 26, 2022.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C24922B0009 0001.pdf | ||
| Germfree 3ft Class II Type A2 BSC BBF-3.pdf | ||
| 621-22-106 C-SCA Bid Specs 2.9.2022.pdf | ||
| Drawings Part 1 of 3 C-SCA 621-22-106 .pdf | ||
| Drawings Part 3 of 3 C-SCA 621-22-106.pdf | ||
| Drawings Part 2 of 3 C-SCA 621-22-106 .pdf | ||
| RFI Form - Mt. Home - Construct Containment Segregated Compounding Area - C-CSCA.pdf | ||
| WD TN 20220111 1-7-2022.pdf | ||
| Specs C-SCA Bid 621-22-106 .pdf | ||
| 36C24922B0009_1.pdf | ||
| 36C24922B0009.docx | DOCX document |
Show all 11
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24922B0009.
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: 236220
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 .