Attachment 13 - EMR Contractor Certification Form.docx
DOCX document 17 KB Posted
- Solicitation number
- 36C77622R0046
About this file
This document contains a certification form for contractors bidding on the EHRM Infrastructure Upgrades project at the Department of Veterans Affairs facility in Martinez, California. To be eligible for consideration, bidders must self-certify that they have no more than three serious or one repeat or willful Occupational Safety and Health Administration violations, or any Environmental Protection Agency violations, in the past three years. They must also have an Experience Modification Rate of 1.0 or less as designated by their insurance carrier for the years 2019 through 2022. Bidders must provide the requested safety, environmental, and EMR information on company letterhead to be eligible for award of the project.
The related federal contract opportunity is for solicitation number 36C77622R0046 to provide design-build services for the relocation or remodel of approximately 28 telecommunications rooms and one data center at the Martinez VA facility. The selected contractor will design, construct, and close out the project to upgrade the rooms according to VA Office of Information and Technology and EHRM infrastructure standards while maintaining ongoing IT services.
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Text version
EMR Contractor Certification Form
[ INSERT COMPANY LETTER HEAD HERE.] CONTRACTOR CERTIFICATION FORM
Contractor Certification Regarding Project: EHRM Infrastructure Upgrades, Martinez, California RFP # 36C77622R0046
Company Name:
| · Group 1 | ☐Group 2 | (only check one) |
| FACTOR 1 SAFETY - PER VHA DIRECTIVE 7715 (06 April 2017): | SAFETY & ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE (EMR): | To be |
eligible for consideration and award, the contractor shall have no more than three serious, or one repeat, or one willful OSHA or EPA violation(s) in the past 3 years and have an EMR of equal to or less than 1.0.
All Offerors shall submit the following information pertaining to their past Safety & Environmental Record and EMR with their offer:
1. SAFETY & ENVIRONMENTAL RECORD: A self-certification on company letterhead that the bidder has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years. NOTE: completion of this Form constitutes self-certification.
| 2019 |
| 2020 |
| 2021 |
| 2022 |
Number of serious, willful, or repeat violations from OSHA within the last 3 years (November 2017 – November 2018).
Number of EPA violations within the last 3 years (November 2017 – November 2020).
| 2019 |
| 2020 |
| 2021 |
| Current |
EMR Ratings designated by Insurance Carrier If no EMR for any year(s), insert “N/A” and provide an explanation below. A “N/A” will be given a default score of 1 for that year(s).
If no EMR for any of these years, briefly explain why here:
File details come from the government source that posted it. Updated .