S02 - ATTACHMENT 12 EMR Contractor Certification Form.docx
DOCX document 17 KB Posted
- Attached to
- Y1AZ--(640A4-21-703) EHRM Training and Administrative Support Space Construction - Livermore, CA
- Solicitation number
- 36C77622R0043
About this file
This document contains a federal contract opportunity notice and an associated contractor certification form. The Department of Veterans Affairs is seeking proposals for a design-build contract to prepare site utilities for electronic health record management trailers at the Veterans Affairs Palo Alto Health Care System Livermore campus. Offerors must be service-disabled veteran-owned small businesses. The contractor will provide design and construction services to install power, water, sewer and telecommunications utilities to trailers as indicated in an exhibit, along with any required site preparation work including grading, leveling and walkways. The solicitation will be issued in late February to early March 2022 as a request for proposal conducted under FAR Part 36.3 procedures. The estimated value is between $500,000 and $1,000,000 and the period of performance is approximately 300 calendar days from notice to proceed. The associated contractor certification form requires bidders to disclose safety and environmental violations and experience modification ratings for the past three years.
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Text version
EMR Contractor Certification Form
[ INSERT COMPANY LETTER HEAD HERE.] CONTRACTOR CERTIFICATION FORM
Contractor Certification Regarding Project: EHRM Infrastructure Upgrades, McClellan, California RFP # 36C77622R0047
Company Name:
| · Group 1 | ☐Group 2 | (only check one) |
| FACTOR 1 SAFETY - PER VHA DIRECTIVE 7715 (06 April 2017): | SAFETY & ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE (EMR): | 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 bidder 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. NOTE: completion of this Form constitutes self-certification.
| 2019 |
| 2020 |
| 2021 |
| 2022 |
Number of serious, willful, or repeat violations from OSHA within the last 3 years (November 2017 – November 2018).
Number of EPA violations within the last 3 years (November 2017 – November 2020).
| 2019 |
| 2020 |
| 2021 |
| Current |
EMR Ratings designated by Insurance Carrier If no EMR for any year(s), insert “N/A” and provide an explanation below. A “N/A” will be given a default score of 1 for that year(s).
If no EMR for any of these years, briefly explain why here:
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