Attachment - III - Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Attached to
- Renovate Building 16, 610-20-103 Federal contract opportunity
- Solicitation number
- 36C25025B0005
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form that contractors must complete for Project 610-20-103, which involves renovating Building 16 at the Marion VA Medical Center. The form requires contractors to provide detailed safety statistics from their OSHA 300 Forms for years 2020-2023, including man hours worked, cases involving days away from work or restricted activity, DART rates, and any OSHA violations.
The form requires submission of OSHA 300 and 300a Forms, the company's six-digit NAICS code, information about who administers their Safety and Health Program, and the company's Insurance Experience Modification Rate (EMR). This safety evaluation is part of the pre-award process for a renovation project that will house the VA Northern Indiana Health Care System's Executive Leadership Team and administrative departments in Building 16 of the Marion Campus.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Project 610-20-103:
Company Name: Address: Telephone: Fax: Email: Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2020 |
| 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:
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 .