Contractor EMR Certification Form.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C24923B0011
About this file
This document contains a pre-solicitation notice and contractor safety evaluation form. The Department of Veterans Affairs Network Contracting Office 9 Central Region will solicit bids by April 28, 2023 for construction services for VA Project #621-22-113 to replace the domestic water piping in Building 160 at the James H. Quillen VA Medical Center in Mountain Home, Tennessee. The project magnitude is estimated between $2,000,000 to $5,000,000. The NAICS code is 238290 and the small business size standard is $22 million. The period of performance is 423 calendar days from notice to proceed. The acquisition is set aside 100% for Service-Disabled Veteran-Owned Small Businesses. The contractor safety evaluation form requests company safety information including OSHA recordable incident rates for the past three years and insurance experience modification rate.
View the file
Other files
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 36C24922B0018
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2019 |
| 2020 |
| 2021 |
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: 238210
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 .