Attachment 5 - Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24923R0046
About this file
This document contains a pre-award contractor safety evaluation form and details of a federal contract opportunity to replace flooring in the Emergency Department at the Troy Bowling Campus of the Lexington VA Medical Center in Lexington, Kentucky. The evaluation form requests contact information and safety data including total man hours, OSHA recordable incidents, injury rates, violations, and insurance experience modification rate from prospective contractors. The federal contract opportunity involves demolishing and removing existing doors and flooring then installing new doors and flooring per drawings and specifications. The justification provided is that the current flooring has holes and cracks throughout and needs replacing to avoid injuries. The solicitation number is 36C24923R0046 and is being conducted by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24923R0046
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 .