Attachment 6 Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Attached to
- Y1DA--603-24-101 - Construction to Correct Physical Security Deficiencies Federal contract opportunity
- Solicitation number
- 36C24925B0003
About this file
The document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24925B0003, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The form requires contractors to provide detailed safety and workplace injury data from 2022-2024, including total man-hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rate, and OSHA violation history.
Specific requirements include submitting OSHA 300 and 300a Forms, providing the six-digit NAICS code (236220 for this acquisition), identifying the administrator of the company's Safety and Health Program, and disclosing the company's Insurance Experience Modification Rate (EMR). The associated federal contract opportunity is for construction to correct physical security deficiencies, specifically related to CLC Road Repaving, indicating a facilities improvement project for a Veterans Affairs facility.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Attachment 3 Site Plan FEB 2018.pdf | ||
| 36C24925B0003 0002.docx | DOCX document | |
| Attachment 2 RFI Responses _ 603-24-101.pdf | ||
| Attachment 1 Site-Visit Sign-In Sheet.pdf | ||
| 36C24925B0003 0001.docx | DOCX document | |
| Attachment 8 Wage Determination KY20250093 - Modification 5 - 04-11-25.pdf | ||
| Attachment 5 General Conditions Breakout.xlsx | XLSX spreadsheet | |
| Attachment 4 Calculation of Self Performed Work.xlsx | XLSX spreadsheet | |
| 36C24925B0003_1.docx | DOCX document | |
| Attachment 2 RRVAMC Bid Drawings.pdf | ||
| Attachment 1 Bid Specifications.pdf | ||
| Attachment 7 Request For Information Form.docx | DOCX document | |
| Attachment 3 Pricing Schedule.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 36C24925B0003
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: 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 .