Attachment 6 Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24925B0001
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24925B0001, related to a road repaving project at the Franklin R Sousley Campus of the Lexington VAMC. The form requires contractors to provide comprehensive safety and health information, including OSHA 300 Forms documenting man hours, workplace injury cases, DART (Days Away, Restricted, or Transferred) rates, and any OSHA violations for the years 2022-2024.
The form requests specific documentation such as OSHA 300 and 300A Forms, the company's six-digit NAICS code (237310 for Highway, Street, and Bridge Construction), details about the company's Safety and Health Program administrator, and the company's Insurance Experience Modification Rate (EMR). This evaluation is part of the Department of Veterans Affairs Veterans Health Administration's procurement process for the road repaving project, with the goal of assessing contractor safety performance and compliance.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24925B0001 0003.docx | DOCX document | |
| 36C24925B0001 0002.docx | DOCX document | |
| Attachment 3 Revised Combined SOW - PLANS- SPECIFICATIONS - 04-25-25.pdf | ||
| 36C24925B0001 0001.docx | DOCX document | |
| Attachment 1 Pre-Bid Sign-in Sheet - 596-25-104.pdf | ||
| Attachment 2 RFI Responses - 596-25-104 - CLC - Road Repaving - 04-25-25.pdf | ||
| Attachment 4 Calculation of Self Performed Work.xlsx | XLSX spreadsheet | |
| Attachment 8 Wage Determination - KY20240082 - Modification - 01-03-25.pdf | ||
| Attachment 2 Drawing S-001 Final.pdf | ||
| Attachment 3 Pricing Schedule.xlsx | XLSX spreadsheet | |
| Attachment 1 Combined Specifications - Bid Docs - 596-25-104.pdf | ||
| 36C24925B0001_1.docx | DOCX document | |
| Attachment 7 Request For Information Form.docx | DOCX document | |
| Attachment 5 General Conditions Breakout.xlsx | XLSX spreadsheet |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24925B0001
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 .