Attachment 4 - Contractor EMR Certification Form.docx

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Attached to
603-24-105 – Replace Medical Air and Vacuum Pumps Bldg. 1
Solicitation number
36C24924R0038
Issued by

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This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity for replacing medical air and vacuum pumps at a Veterans Affairs medical center. The evaluation form requests information on the contractor's number of man hours, OSHA recordable incidents, days away from work rates, and serious safety violations over the past three years. It also asks for the contractor's North American Industry Classification System code and details on its safety program administration and insurance experience modification rate. The related federal contract opportunity is solicitation number 36C24924R0038 to replace medical air and vacuum pumps at the Robley Rex VAMC in Louisville, Kentucky issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9.

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Other files

File Type Posted
36C24924R0038 P0002.pdf PDF
Site-Visit Sign Sheet - 02-09-2024.pdf PDF
36C24924R0038 0001.pdf PDF
Attachment 3 - Wage Determination KY20230093 - Modification 0 - 01-05-2024.pdf PDF
Attachment 5 - Calc. of Self Performed Work General Contractor.xlsx XLSX spreadsheet
Attachment 2 Past Performance Questionnaire.pdf PDF
Attachment 1 - Specifications.pdf PDF
36C24924R0038.pdf PDF
Attachment 6 - Price Schedule Project 603-24-105.xlsx XLSX spreadsheet

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Pre-Award Contractor Safety and Environmental Record Evaluation Form

Information provided below is current and applicable to Solicitation 36C24924R0018

Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________

1. Utilizing your OSHA 300 Forms, please complete the following information:

Category
2020
2021
2022

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: 238220

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 .