Attachment 14 - EMR Contractor Certification Form.docx
DOCX document 17 KB Posted
- Solicitation number
- 36C77622R0047
About this file
This document contains a certification form and information on a federal contract opportunity for EHRM infrastructure upgrades at the McClellan VA Medical Center in California. The certification form requires contractors to self-certify that they have no more than three serious, one repeat, or one willful OSHA or EPA violations in the past three years and an EMR of 1.0 or less. It requests information on safety and environmental records from 2019 to 2022 as well as current EMR ratings.
The federal contract opportunity involves providing design-build services to upgrade approximately 19 telecommunications rooms and one data center to meet VA EHRM IT standards. Scope of work includes upgrading communication infrastructure with Cat 6A cabling; installing new redundant fiber backbone; upgrading room fittings, raceways, and mechanical systems; renovating spaces; removing legacy equipment; and testing and commissioning systems. The selected contractor must also extend utilities to a training trailer area and schedule phasing, cutovers, and weekend/holiday work.
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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, McClellan, California RFP # 36C77622R0047
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 .