Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Attached to
- 626-24-203_Cooling Tower and Chillers
- Solicitation number
- 36C24926R0054-1
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form required for Solicitation 36C24926R0021 related to Project 626-24-203 Cooling Tower and Chillers for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The form is a template designed to collect critical safety and health data from prospective contractors prior to contract award.
Contractors must provide company identification information and complete a three-year safety record summary (2023, 2025, 2025) including total man hours worked at jobsite and office locations, the number of OSHA recordable cases involving days away from work or restricted activity, and the Days Away, Restricted, or Transferred (DART) rate calculated using the standard OSHA formula. Additionally, contractors must disclose the number of serious, willful, or repeat OSHA violations incurred within the past three years with explanatory attachments for any violations cited. Supporting documentation requirements include copies of OSHA 300 and 300a Forms. Contractors must also provide their six-digit North American Industrial Classification System (NAICS) code, identify the individual or department administering the company's Safety and Health Program, and submit their current Insurance Experience Modification Rate (EMR). This evaluation form is a pre-qualification tool used to assess contractor safety performance and risk prior to contract award.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24926R0021
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2023 |
| 2024 |
| 2025 |
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 .