Atch 7 Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24926R0065
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form required for Solicitation 36C24926R0013. Contractors must submit documentation demonstrating their safety and environmental compliance records to be considered responsible for award. The form requires submission of OSHA 300 and 300a Forms covering three years (2023, 2024, 2025) with specific metrics including total man hours, number of cases involving days away from work or restricted activity, Days Away Restricted Transferred (DART) rates calculated using the standard formula, and documentation of any serious, willful, or repeat OSHA violations within the past three years with explanations. Additionally, contractors must provide their six-digit NAICS code, identify the individual administering the company's Safety and Health Program, and submit their current Insurance Experience Modification Rate (EMR).
This evaluation form is associated with Solicitation 36C24926R0065 for Video Surveillance Security services at the Tennessee Valley Healthcare System (TVHS) Nashville Campus, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The procurement is a 100% set-aside for Service-Disabled Veteran Owned Small Businesses (SDVOSBs) under 38 U.S.C. Section 8127(d), with the NAICS code 238210 (Electrical Contractors and Other Wiring Installation Contractors) and a small business size standard of $45 million. Offerors must maintain active listings in both the SBA SDVOSB database and SAM, and the awarded contractor must provide evidence of VETS4212 enrollment.
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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 .