Atch 7 Contractor EMR Certification Form.docx
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- Solicitation number
- 36C24926R0064
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form that contractors must complete as part of Solicitation 36C24926R0064 for video surveillance security services at the Tennessee Valley Healthcare System (TVHS) Alvin C. York Campus in Murfreesboro, Tennessee. The form requires contractors to provide company identifying information and documentation of their safety and health performance metrics from the past three years (2023-2025), including total man-hours worked, OSHA 300 and 300a forms, the number of cases involving days away from work or restricted activity, calculation of DART rates, and disclosure of any serious, willful, or repeat OSHA violations with explanatory documentation.
Additionally, contractors must provide their six-digit NAICS code (238210 for Electrical Contractors), identify the administrator of their company's Safety and Health Program, and report their Experience Modification Rate (EMR) from their insurance carrier. This evaluation form is a mandatory pre-award submission requirement used by the Contracting Officer to assess contractor responsibility and safety compliance prior to making an award decision. The solicitation is a 100% set-aside for Service-Disabled Veteran Owned Small Business (SDVOSB) concerns, with awardees required to be listed in the SBA VOSB database, maintain active SAM.gov registration, and enroll with VETS4212.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24926R0013
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2023 |
| 2024 |
| 2025 |
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 six-digit North American Industrial Classification System (NAICS) Code for this acquisition:
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 .