Attachment 2 - Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C249R0048
About this file
This document is a Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24924R0018. It requires the contractor to provide information on their 2020-2022 OSHA 300 forms, including number of man-hours, number of cases involving days away from work, their DART rate, and any serious, willful, or repeat OSHA violations in the last 3 years. The contractor must also provide their 6-digit NAICS code, who administers their safety and health program, and their current Insurance Experience Modification Rate (EMR). The related federal contract opportunity is to Install a New CO2 Monitoring System for the Boiler Plant at the Troy Bowling Campus of the Lexington VA Health Care System, as required by VA Directive 1810.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24924R0018
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2020 |
| 2021 |
| 2022 |
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: 238220
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 .