Attachment 7 Contractor EMR Certification.docx
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- Solicitation number
- 36C24925R0003
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form (Attachment 7) for solicitation 36C24925R0003, which requires contractors to provide detailed safety performance data. The form requests information about OSHA incident rates and documentation for the years 2022-2024, including man-hours worked, cases involving days away from work, DART rates, and any OSHA violations. Contractors must submit OSHA 300 and 300a forms, identify their NAICS code (236220), provide information about their Safety and Health Program administrator, and report their Insurance Experience Modification Rate (EMR).
The form relates to a construction project at the Lexington VA Healthcare System for replacing deteriorated underground utilities (water, sanitary & storm drain distribution). This is a 100% SDVOSB set-aside with an estimated value between $5-10 million, being procured through FAR Part 15 as an LPTA source selection. The work requires consideration of infection control, demolition noise, and environmental dust control due to the medical facility setting.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24925R0003
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 .