ATTACHMENT 5- Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24923R0032
About this file
This document contains a pre-award contractor safety evaluation form and details of a federal contract solicitation for construction services. The solicitation is for project number 603-22-101 to replace operating rooms 1 through 3 supply heads at the Robley Rex VA Medical Center in Louisville, Kentucky. The project magnitude is between $500,000 and $1,000,000, and the NAICS code is 236220 for commercial and institutional building construction. The small business size standard is $39.5 million. The selected contractor must provide all labor, materials, equipment, transportation, and supervision to complete the preparation, demolition, construction, HVAC, plumbing, building envelope, electrical, and finish work. The anticipated completion schedule is 270 calendar days from notice to proceed. The solicitation is set aside 100% for service-disabled veteran-owned small businesses.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24923R0032
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 .