Atch 5 Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Attached to
- Y1DA--621-22-129 - Bldg 160 Kitchen AHU-4 Replacement Federal contract opportunity
- Solicitation number
- 36C24925B0005
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24925B0005. The form requires contractors to provide detailed safety and health information, including OSHA 300 Forms data for 2022-2024, such as man hours, workplace injury cases, days away/restricted work rates, and OSHA violations. Contractors must submit documentation including OSHA 300 and 300A Forms, provide their six-digit NAICS code (236220 - Commercial and Institutional Building Construction), identify who administers their safety program, and disclose their Insurance Experience Modification Rate (EMR).
The related federal contract opportunity is for the James H. Quillen VA Medical Center in Mountain Home, Tennessee, specifically a project to replace the AHU-4 in Building 160's kitchen mechanical room. The project involves site preparation, demolition, and installing a new HVAC system to condition the kitchen hood supply. The contract has a 180-calendar day performance period after Notice to Proceed, with work permitted during nights and weekends to maintain kitchen operations. All work and materials will be warranted for one year, and the project is being executed by the Department of Veterans Affairs Veterans Health Administration.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Atch 9 Sign In Sheet 06162025.pdf | ||
| Atch 1 WD Washington County Building TN20250191 dated 06062025.pdf | ||
| 36C24925B0005 0001.docx | DOCX document | |
| Atch 6 General Conditions Breakout.xlsx | XLSX spreadsheet | |
| Atch 3 Drawings 06032025.pdf | ||
| Atch 1 WD Washington County Building TN20250191 dated 05022025.pdf | ||
| 36C24925B0005_1.docx | DOCX document | |
| Atch 8 RFI Form.docx | DOCX document | |
| Atch 7 Price Breakout Schedule.xlsx | XLSX spreadsheet | |
| Atch 2 Specifications 05282025.pdf | ||
| Atch 4 Calculation of Contractor Self Performed Work.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: 36C24925B0005
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 .