Attachment 5 Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Attached to
- Y1PZ--603-25-908 - Storm and Snow Damage Repairs
- Solicitation number
- 36C24925B0009
About this file
The document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24925B0009, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9 for Storm and Snow Damage Repairs. The form requires contractors to provide detailed safety and health information, including OSHA 300 Form data for 2022-2024, covering man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations.
Contractors must submit their six-digit NAICS Code (237310), identify who administers their Safety and Health Program, and disclose their Company's Insurance Experience Modification Rate (EMR). The form mandates attachment of OSHA 300 and 300a Forms, which can be accessed through the OSHA publications search page. This evaluation form is part of the pre-award assessment process for a storm and snow damage repair project, focusing on contractor safety performance and environmental record.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24925B0009 0002.docx | DOCX document | |
| 36C24925B0009 0001.docx | DOCX document | |
| Attachment 4 General Conditions Breakout.xlsx | XLSX spreadsheet | |
| Attachment 2 Pricing Schedule.xlsx | XLSX spreadsheet | |
| Attachment 1 Drawings - S-1.pdf | ||
| 36C24925B0009_1.docx | DOCX document | |
| Attachment 3 Calculation of Self Performed Work.xlsx | XLSX spreadsheet | |
| Attachment 6 Request For Information Form.docx | DOCX document | |
| Attachment 7 Wage Determination - KY20250093 - Modification 6 - 6-6-25.pdf |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24925B0009
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2022 |
| 2023 |
| 2024 |
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: 237310
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 .