Attachment 6 - Contractor EMR Certification Form.docx
DOCX document 18 KB Posted
- Attached to
- Z2DA--Renovate Hot Lab 539-26-502
- Solicitation number
- 36C25026Q0424
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form (Contractor EMR Certification Form) that contractors must complete for consideration on Project 539-26-502, the Z2DA—Renovate Hot Lab project for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10.
The form requires contractors to provide comprehensive safety and health performance data across four years (2022–2025), including total man hours worked at jobsites and offices, number of cases involving days away from work or restricted activity, and calculated DART rates (Days Away, Restricted, or Transferred rates). Contractors must disclose any serious, willful, or repeat OSHA violations incurred within the preceding three years and provide supporting explanations. Additionally, contractors must submit copies of OSHA 300 and 300A Forms, identify their six-digit NAICS code (236220 specified for this acquisition), name the administrator of their Safety and Health Program, and provide their company's Insurance Experience Modification Rate (EMR). This safety and environmental evaluation is conducted pre-award to assess contractor qualifications and historical safety performance for the renovation project.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C25026Q0424 0003.docx | DOCX document | |
| 36C25026Q0424 0002.docx | DOCX document | |
| 36C25026Q0424 0001.docx | DOCX document | |
| Updated drawings and finish schedules.pdf | ||
| Attachment 2 - VHA Directive 1192.01, Seasonal Influen..pdf | ||
| 36C25026Q0424.docx | DOCX document | |
| Attachment 7 - Request for Information.docx | DOCX document | |
| Attachment 3 - Specifications.pdf | ||
| Attachment 5 - Instructions for VAAR 852.219-75.docx | DOCX document | |
| Attachment 4 - Drawing Set.pdf | ||
| Attachment 1 - Wage Determination OH20260082 01022026.pdf |
Show all 11
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 Project 539-26-502:
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 .