ATTACHMENT 5 Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24926R0037_0001
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form required for Solicitation 36C24926R0037_1, a construction project to renovate Building 1 Primary Care at the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The form is a template and appendix used to assess contractor safety and environmental compliance prior to contract award.
Contractors must submit detailed occupational safety and health information including OSHA 300 and 300A forms for the three-year period covering 2023, 2025, and 2026. Required data elements include total man-hours worked, the number of cases involving days away from work or restricted activity, the Days Away, Restricted, or Transferred (DART) rate calculation, and the count of serious, willful, or repeat OSHA violations with supporting explanations. Additionally, contractors must provide their six-digit North American Industrial Classification System (NAICS) code (236220 for construction), identify the administrator of their company's Safety and Health Program, and disclose their Experience Modification Rate (EMR) from their insurance provider. All supporting documentation must be attached to the submission.
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Other files
| File | Type | Posted |
|---|---|---|
| Addendum 2_Cover Sheet.pdf | ||
| Addendum 2_Revised Drawings.pdf | ||
| Addendum 2_Revised Specifications.pdf | ||
| Addendum 2_Questions and Answers.pdf | ||
| 36C24926R0037 0004.docx | DOCX document | |
| 36C24926R0037 0003.docx | DOCX document | |
| 36C24926R0037 0002.docx | DOCX document | |
| Sign Proof.pdf | ||
| Sign Schedule.pdf | ||
| Solicitation Questions and Answers_614-17-113.pdf | ||
| Site Visit Sign-in Sheet_36C24926R0037.pdf | ||
| 36C24926R0037 0001.docx | DOCX document | |
| ATTACHMENT 8 Past Performance Questionnaire_614-17-113.pdf.pdf | ||
| ATTACHMENT 7 Price Breakout Schedule.xlsx | XLSX spreadsheet | |
| ATTACHMENT 1 Project Specifications Vol 1 of 2_614-17-113.pdf | ||
| ATTACHMENT 6 General Conditions Breakout.xlsx | XLSX spreadsheet | |
| ATTACHMENT 2 Project Specifications Vol 2 of 2_614-17-113.pdf | ||
| ATTACHMENT 9 DBA Wage Determination TN20260200 5-18-2026.pdf | ||
| ATTACHMENT 3 Project Drawings_614-17-113.pdf | ||
| ATTACHMENT 4 Calc. of Self Performed Work.xlsx | XLSX spreadsheet | |
| 36C24926R0037_1.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24926R0037_1
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2023 |
| 2024 |
| 2025 |
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 .