Atch 13 Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Attached to
- Z1DA--626-24-204 - Update / Upgrade Steam System Components Federal contract opportunity
- Solicitation number
- 36C24924B0011
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form related to Solicitation 36C24924B0011 for the Department of Veterans Affairs Tennessee Valley Healthcare System (TVHS) to upgrade the steam system components at the Nashville VA Medical Center.
The key details are: The contractor must provide information on their OSHA 300 forms, NAICS code, safety program administrator, and insurance experience modification rate (EMR). The scope of work includes replacing condensate return skid pumps, piping, and associated components, as well as adding venting in various areas of the medical center. The contractor must follow all applicable state, local, and federal codes and regulations, provide a schedule, and coordinate the work to minimize disruptions to the occupied medical center. The period of performance is 120 calendar days from the notice to proceed. Warranty requirements and other project guidelines are also specified.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation: 36C24924B0011
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 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 your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 238220 – Plumbing, Heating, and Air-Conditioning Contractors
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 .