Atch 5 Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Attached to
- Z1DA--626A4-23-203 - Upgrade Fire Alarm System
- Solicitation number
- 36C24925R0005
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form that contractors must complete for Solicitation 36C24925R0005, a fire alarm system upgrade project at the Tennessee Valley Healthcare System VA Medical Center in Murfreesboro, TN. The form requires contractors to provide detailed safety statistics from their OSHA 300 Forms for 2022-2024, including man-hours worked, cases involving days away from work, DART rates, and any OSHA violations.
The form also requires contractors to confirm their NAICS code (236220 - Commercial and Institutional Building Construction), identify who administers their Safety and Health Program, and provide their Insurance Experience Modification Rate (EMR). Contractors must attach copies of their OSHA 300 and 300a Forms and explain any serious, willful, or repeat OSHA violations from the past three years.
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Other files
| File | Type | Posted |
|---|---|---|
| Atch 11 Sign in Sheet 03122025.pdf | ||
| 36C24925R0005 0001.docx | DOCX document | |
| Atch 2 Drawings 03112025.pdf | ||
| Atch 3 Specifications 03262025.pdf | ||
| Atch 1 WD Rutherford County Building TN20240187 dated 03142025.pdf | ||
| Atch 12 Geotech Report 05162023.pdf | ||
| Atch 1 WD Rutherford County Building TN20240187 dated 01032025.pdf | ||
| Atch 10 RFI Form.docx | DOCX document | |
| Atch 3 Specifications 103124 Final.pdf | ||
| 36C24925R0005_3.docx | DOCX document | |
| Atch 7 Past Performance Questionnaire.docx | DOCX document | |
| Atch 6 General Conditions Breakout.xlsx | XLSX spreadsheet | |
| Atch 2 Drawings 09272024.pdf | ||
| Atch 9 TAX ID UEI Document.docx | DOCX document | |
| Atch 4 Calculation of Contractor Self Performed Work.xlsx | XLSX spreadsheet | |
| Atch 8 Price Breakout Schedule.xlsx | XLSX spreadsheet |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation: 36C24925R0005
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: 236220 – Commercial and Institutional Building Construction
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 .