Attachment 6 Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Attached to
- Y1PZ--603-26-103 - Repair Storm and Snow Damage
- Solicitation number
- 36C24926B0001
About this file
The document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24926B0001, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The form requires contractors to provide detailed safety and health information, including OSHA 300 form data for years 2022-2024, such as total man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and any OSHA violations within the past three years.
Contractors must also submit their six-digit NAICS code (238990), identify the administrator of their Safety and Health Program, and disclose their Company's Insurance Experience Modification Rate (EMR). The solicitation appears to be related to repair work for storm and snow damage, with contractors required to demonstrate their safety record and compliance with occupational health standards as part of the pre-award evaluation process.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24926B0001 0002.docx | DOCX document | |
| Attachment 2 RFI Responses - 603-26-103 - Storm and Snow Damage Repair.pdf | ||
| Attachment 1 Sign In Sheet Site Visit 603-26-103 Repair Storm and Snow Damage.pdf | ||
| 36C24926B0001 0001.docx | DOCX document | |
| Attachment 1 Drawings - S-1 Rev 1.pdf | ||
| Attachment 8 Wage Dermination Number KY20240093 - Modification 9 - 8-22-2025.pdf | ||
| Attachment 4 Calculation of Self Performed Work.xlsx | XLSX spreadsheet | |
| Attachment 3 Pricing Schedule.xlsx | XLSX spreadsheet | |
| Attachment 2 - 17A Drain Issue Image.png | PNG image | |
| 36C24926B0001_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 36C24926B0001
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: 238990
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 .