4 Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Attached to
- Z2DA--626A4-22-211 - AJP-Replace Chilled Water Loop Federal contract opportunity
- Solicitation number
- 36C24924R0074
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form, related to Solicitation 36C24924R0074 for a federal contract opportunity. The form requires the contractor to provide information on their OSHA 300 reporting, including number of man-hours, number of lost-time incidents, incident rates, and any OSHA violations within the last 3 years. The contractor must also provide their North American Industry Classification System (NAICS) code, who administers their safety and health program, and their current Insurance Experience Modification Rate (EMR).
The related federal contract opportunity is for Project # 626A4-22-211 "AJP-Replace Chilled Water Loop" at the Tennessee Valley Healthcare System, VA Medical Center in Murfreesboro, TN. The work includes demolition and new construction, with a NAICS code of 238220 for Plumbing, Heating, and Air Conditioning Contractors. The project magnitude is between $5M and $10M, with a small business size standard of $19M. The contracting agency is the Department of Veterans Affairs, Veterans Health Administration, Veterans Integrated Service Network 9.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C24924R0074 0002.pdf | ||
| Amend 0002 - 18235 GEOTECH REPORT.pdf | ||
| Amend 0002 RFI Responses 626A4-22-211 - Construction AJP Replace Chilled Water Loop.pdf | ||
| Site Visit Scanned Sign In Sheet.pdf | ||
| 36C24924R0074 0001.pdf | ||
| 8 Price Schedule Project 626A4-22-211 AJP-Replace Chilled Water Loop.xlsx | XLSX spreadsheet | |
| 1 Wage Determination TN20240187 06212024 626A4-22-211 Replace Chilled Water Loop.pdf | ||
| 2 AJP-Replace_Chilled_Water_Loop_100_Const_Drawings_2024_01_19.pdf | ||
| 5 RFI Form.docx | DOCX document | |
| 36C24924R0074.pdf | ||
| 3 AJP-Replace_Chilled_Water_Loop_100_Const_Specs_2024_01_19.pdf | ||
| 6 UEI _ TAX ID.docx | DOCX document | |
| 7 Calculation of Self Performed Work.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24924R0074
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2021 |
| 2022 |
| 2023 |
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 Plumbing, Heating, and Air Conditioning Contractors.
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 .