Attachment V - Contractor EMR Certification Form 610-21-214.pdf
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- Solicitation number
- 36C25023B0031
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and details of a related federal contract opportunity for upgrades to utilities and infrastructure at a VA medical facility. The evaluation form requests safety-related documentation and insurance information from prospective contractors bidding on Solicitation Number 36C25023B0031. This solicitation is for upgrades to mechanical systems, lighting, plumbing, and fire protection at VA Northern Indiana Health Care - Marion Campus to provide workspace for expanded home health care services. Prospective contractors must provide OSHA 300 forms, NAICS code, safety program administration, and experience modification rate. An on-site pre-bid meeting is scheduled for May 2, 2023 at 10:00 am at the medical facility.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Project 610-21-214:
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2018 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: 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 .