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, which pertains to a Department of Veterans Affairs construction project to replace main electrical distribution equipment at a Veterans Integrated Service Network 9 facility (Project #596A4-24-101). The form is a template designed to collect detailed occupational safety and health information from prospective contractors as part of the pre-award evaluation process.
Contractors are required to provide company identification information and complete a comprehensive three-year safety record summary covering 2023, 2025, and calendar year data including total man hours, DART rates (days away, restricted, or transferred cases), and the number of serious, willful, or repeat OSHA violations. Supporting documentation must include copies of OSHA 300 and 300a Forms, along with explanations for any violations cited. Additionally, contractors must supply their six-digit NAICS code (236220 for the construction classification), identify the administrator of their Safety and Health Program, and provide their company's Insurance Experience Modification Rate (EMR). This information allows the contracting officer to assess contractor safety performance and compliance history prior to award.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24926R0073 0005.docx | DOCX document | |
| Addendum 001_Scope Clarification.pdf | ||
| 36C24926R0073 0004.docx | DOCX document | |
| Solicitation Questions and Answers 2_36C24926R0073.pdf | ||
| 36C24926R0073 0003.docx | DOCX document | |
| VAMC_LEX_Bowling.pdf | ||
| Solicitation Questions and Answers_36C24926R0073.pdf | ||
| 36C24926R0073 0002.docx | DOCX document | |
| SK_TB MV_01.pdf | ||
| 36C24926R0073 0001.docx | DOCX document | |
| Site Visit Sign-in Sheet_36C24926R0073.pdf | ||
| ATTACHMENT 7 Price Breakout Schedule.xlsx | XLSX spreadsheet | |
| ATTACHMENT 3 Project Drawings 596A4-24-101.pdf | ||
| ATTACHMENT 8 Past Performance Questionnaire 596A4-24-101.pdf | ||
| ATTACHMENT 2 Project Specifications - Coordination Study 596A4-24-101.pdf | ||
| ATTACHMENT 1 Project Specifications 596A4-24-101.pdf | ||
| ATTACHMENT 9 DBA Wage Determination KY20260090 5-18-2026.pdf | ||
| ATTACHMENT 6 General Conditions Breakout.xlsx | XLSX spreadsheet | |
| ATTACHMENT 4 Calc. of Self Performed Work.xlsx | XLSX spreadsheet | |
| 36C24926R0073_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 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 .