Attachment 6 Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Solicitation number
- 36C24925B0014
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24925B0014, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The form requires contractors to provide detailed safety and environmental performance data, including OSHA 300 form information for 2022-2024, such as man-hours, workplace injury cases, days away/restricted work rates, and OSHA violations. Contractors must also submit their six-digit NAICS code (236220), identify who administers their Safety and Health Program, and disclose their Experience Modification Rate (EMR). The solicitation appears to be for a project to replace cast iron steam distribution, with contractors required to demonstrate their safety record and compliance through comprehensive documentation.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C24925B0014 0001.docx | DOCX document | |
| Attachment 4 Calculation of Self Performed Work.xlsx | XLSX spreadsheet | |
| Attachment 8 Wage Determination KY20250090 - Modification 8 -08-22-2025.pdf | ||
| Attachment 5 General Conditions Breakout.xlsx | XLSX spreadsheet | |
| Attachment 1 Drawing - Campus Map.pdf | ||
| Attachment 7 Request For Information Form.docx | DOCX document | |
| Attachment 3 Pricing Schedule.xlsx | XLSX spreadsheet | |
| Attachment 2 Pressure Fitting Survey.pdf | ||
| 36C24925B0014_1.docx | DOCX document |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24925B0014
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 .