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 Pre-Award Contractor Safety and Environmental Record Evaluation Form required for Solicitation 36C24926R0073_1, a Department of Veterans Affairs construction project to replace main electrical distribution equipment at a Veterans Integrated Service Network 9 facility. The form functions as a template for contractors to submit safety and environmental compliance documentation as part of the pre-award evaluation process.
Contractors must provide detailed occupational safety information covering the three-year period from 2023 through 2025, including total man-hours worked at jobsites and offices, the number of cases involving days away from work or restricted activity (DART Rate), and documentation of any serious, willful, or repeat OSHA violations. Supporting documentation requirements include copies of OSHA 300 and 300a Forms. Additionally, contractors must supply their six-digit NAICS code (with 236220 referenced as an example), identify the individual responsible for administering the company's Safety and Health Program, and provide their Insurance Experience Modification Rate (EMR). This evaluation criterion is designed to assess contractor safety performance and environmental compliance capabilities 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 .