Atch 4 Contractor EMR Certification Form.docx
DOCX document 18 KB Posted
- Attached to
- Y1PZ--Concrete Repairs B2, B43, B45, B160 & B162
- Solicitation number
- 36C24926R0030
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24926R0030, which requires contractors to provide detailed safety and health information. The form requests comprehensive safety documentation, including OSHA 300 Forms covering man hours, workplace incidents, days away from work, and violation history for the years 2022-2024. Contractors must provide their six-digit NAICS code (238110 - Poured Concrete Foundation and Structure Contractors), identify who administers their safety program, and disclose their Company's Insurance Experience Modification Rate (EMR).
The related federal contract opportunity is for concrete repairs at the James H. Quillen VA Medical Center in Mountain Home, Tennessee, involving repairs and replacements at buildings 2, 45, 46, 160, and 162. The project scope includes demolishing and replacing damaged sidewalks, leveling concrete, removing trip hazards, and reconstructing a basketball court with steel-reinforced concrete. The work is to be completed within 39 calendar days after receiving the Notice to Proceed, with a one-year warranty, and requires proper disposal of demolition debris while minimizing disruption to traffic and pedestrian flow.
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Other files
| File | Type | Posted |
|---|---|---|
| Atch 9 Specification.pdf | ||
| 36C24926R0030 0001.docx | DOCX document | |
| Atch 8 Drawings.pdf | ||
| Atch 7 RFI Form.docx | DOCX document | |
| Atch 6 Price Breakout Schedule.xlsx | XLSX spreadsheet | |
| Atch 5 General Conditions Breakout.xlsx | XLSX spreadsheet | |
| Atch 3 Calculation of Contractor Self Performed Work.xlsx | XLSX spreadsheet | |
| Atch 2 TAX ID UEI Information.docx | DOCX document | |
| Atch 1 WD Washington County Building TN20260191 dated 01012026.pdf | ||
| 36C24926R0030_1.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation: 36C24926R0030
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2022 |
| 2023 |
| 2024 |
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: 238110 – Poured Concrete Foundation and Structure 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 .