SAFETY - ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE -Attachment 3.pdf
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- Solicitation number
- 36C26126R0048
About this file
This is a contractor certification template for safety and environmental record requirements per VHA Directive 7715 (06 April 2017). All offerors must submit documentation demonstrating compliance with eligibility criteria and past performance standards to be considered for award.
Contractors must certify on company letterhead that they have no more than three serious violations, one repeat violation, or one willful OSHA or EPA violation within the past three years. Four serious violations, one repeat violation, or one willful violation disqualifies the contractor from consideration. Additionally, all offerors must submit their current Experience Modification Rate (EMR) obtained from their insurance carrier on the carrier's letterhead, with an EMR equal to or less than 1.0 required for eligibility. If an offeror's EMR exceeds 1.0, they must provide a written explanation from their insurance carrier describing the reasons for the elevated rate and the anticipated date for reduction to 1.0 or below. The certification form requires offerors to report the number of OSHA violations and EPA violations for each year within the last three years (2023, 2024, 2025), with explanations attached for any violations. The form concludes with signature and printed name fields from an authorized company representative.
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Text version
PER VHA DIRECTIVE 7715 (06 April 2017) - SAFETY &
ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE
(EMR):
Contractor Certification Regarding Project:
To be eligible for consideration and award, the contractor shall have no more than three serious, or one repeat, or one willful OSHA or EPA violation(s) in the past 3 years and have an EMR of equal to or less than 1.0.
All Offerors shall submit the following information pertaining to their past Safety & Environmental Record and EMR with their offer.
1. SAFETY & ENVIRONMENTAL RECORD: A self-certification on company letterhead that the contractor has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years.
2. EMR: All Offerors shall submit information regarding their current EMR. This information shall be obtained from the Offerors’s insurance carrier and be furnished on the insurance carrier’s letterhead. If an Offeror’s EMR is above 1.0, Offeror shall submit a written explanation of the EMR from its insurance carrier furnished on the insurance carrier’s letterhead, describing the reasons for the EMR, and the anticipated date the EMR may be reduced to 1.0 or below.
2023 2024 2025
Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations. (Four serious, one repeat, or one willful disqualifies the contractor.)
Number of violations from EPA within the last
3 years. Please attach explanation for any violations.
Company’s Current Insurance Experience Modification Rate (EMR) =
(Note: Contractor must support the EMR with a signed letter from
Insurance Carrier on their letterhead.)
Signature:
Print Name: _________________________________________________
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