ATTACHMENT 2 Contractor EMR Certification Form.docx

This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form (Attachment 2) required for solicitation 36C24926R0077, the Y1DA Project #596-26-4 FMS Boiler Replacement for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The form is a template designed to collect and evaluate contractor safety and environmental performance data prior to contract award.

Contractors must provide comprehensive occupational safety information for three years (2024, 2025, 2026), including total man-hours worked, the number of cases involving days away from work or restricted activity per OSHA 300 Forms, and calculated DART rates (days away, restricted, or transferred cases multiplied by 200,000 divided by total man-hours). Additionally, contractors must disclose the number of serious, willful, or repeat OSHA violations received within the last three years and provide explanations for any violations cited. Contractors must also supply their six-digit NAICS code (specified as 238220 for Plumbing, Heating, and Air-Conditioning Contractors for this acquisition), identify the administrator of their Safety and Health Program, and provide their company's Insurance Experience Modification Rate (EMR). Supporting documentation required includes copies of OSHA 300 and 300a Forms, accessible through the OSHA publications search page. The form requests standard contractor identification information including company name, address, telephone, fax, email, and primary contact person.