Atch 5 Contractor EMR Certification Form.docx

This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form that contractors must complete as part of their proposal submission for solicitation 36C24926R0044. The form requires contractors to provide comprehensive safety and health information covering a three-year period (2022-2024), including OSHA 300 and 300A form data, total man hours worked on jobsites and in offices, number of cases involving days away from work or restricted activity, calculated DART rates, and documentation of any serious, willful, or repeat OSHA violations within the past three years with explanations. Additionally, contractors must identify their six-digit NAICS code (238160 for Roofing Contractors), designate the individual responsible for administering their company's Safety and Health Program, and provide their company's Insurance Experience Modification Rate (EMR).

This evaluation form is a template document requiring contractor-specific information to be inserted in designated fields. Contractors responding to the roofing replacement project at the Lt Col Luke Weathers Jr VA Medical Center in Memphis, Tennessee must complete and submit this form as part of the responsibility determination process. The form directly supports the government's assessment of contractor qualifications and safety performance prior to award, which is a mandatory requirement under FAR Part 9 for this Service-Disabled Veteran Owned Small Business set-aside solicitation.