Attachment 6 - Contractor EMR Certification Form.docx
DOCX document 18 KB Posted
- Attached to
- Z2DA--Replace iDXA C211 539-26-505
- Solicitation number
- 36C25026Q0375
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form that contractors must complete to demonstrate their occupational safety and health performance for the Department of Veterans Affairs project 539-26-505 (Replace iDXA C211).
The form requires contractors to provide comprehensive safety metrics from their OSHA 300 Forms covering 2022 through 2025, including total man hours worked, number of cases involving days away from work or restricted activity, and calculated DART rates. Contractors must also disclose any serious, willful, or repeat OSHA violations from the preceding three years with accompanying explanations. Additional requirements include submitting copies of OSHA 300 and 300a Forms, identifying the six-digit NAICS code (236220 for this acquisition), designating the individual responsible for administering the company's Safety and Health Program, and providing the company's Insurance Experience Modification Rate (EMR). This evaluation form serves as a pre-award criterion for assessing contractor safety and environmental compliance capability for this Veterans Integrated Service Network 10 project.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25026Q0375 0001.docx | DOCX document | |
| Attachment 7 - Request for Information.docx | DOCX document | |
| Attachment 1 - WD OH20260082 01.02.2026.pdf | ||
| Attachment 2 - VHA Directive 1192.01, Seasonal Influen..pdf | ||
| Attachment 3 - Specifications.pdf | ||
| Attachment 5 - Instructions for VAAR 852.219-75.pdf | ||
| Attachment 4 - Drawing Set.pdf | ||
| 36C25026Q0375.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 Project 539-26-505:
Company Name: Address: Telephone: Fax: Email: Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2022 |
| 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 .