ATTACHMENT 5 Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Attached to
- Y1DA--Project # 596A4-24-101 - Construction to Replace Main Electrical Distribution Equipment
- Solicitation number
- 36C24926R0073
About this file
This is a Contractor EMR (Environmental Management Representation) Certification Form template for use in response to solicitation 36C24926R0073, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The form is an appendix or attachment to the solicitation documents and serves as a compliance certification document rather than a substantive statement of work or technical specification.
The form functions as a checklist and attestation mechanism requiring contractors to certify their environmental management practices and compliance status. As a template document, it does not specify products or services required, response dates, award dates, or pricing terms. Instead, it provides a standardized format for contractors bidding on the construction project to Replace Main Electrical Distribution Equipment (Project #596A4-24-101) to document and certify their environmental management representations and commitments prior to contract award.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24926R0073_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 .