ATTACHMENT 5- Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Attached to
- Z2DA--Project 603-22-601 - Post-surgical Patient Safety Improvements - 603-23-3-2311-0003
- Solicitation number
- 36C24923R0031
About this file
This document contains a pre-award contractor evaluation form and details of a federal contract solicitation for construction services. The solicitation is for project number 603-22-601 to provide post-surgical patient safety improvements at the Robley Rex VA Medical Center in Louisville, Kentucky. It is a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses, with a project magnitude between $500,000 and $1 million. The selected contractor must provide all labor, materials, tools, equipment, transportation and supervision to complete site preparation and construction work including demolition, general construction, HVAC, plumbing, building envelope, electrical and finishes. The anticipated completion schedule is 180 calendar days from notice to proceed. Apparent successful offerors must have an updated VETS 4212 report on file with the Department of Labor, be registered in the System for Award Management, and obtain verification of their Service-Disabled Veteran-Owned Small Business status from the Department of Veterans Affairs Center for Veterans Enterprise.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24923R0031
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2019 |
| 2020 |
| 2021 |
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: 236220
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 .