Attachment 7 Contractor EMR Certification.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24925R0040
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24925R0040, issued by the Department of Veterans Affairs Veterans Health Administration. The form requires contractors to provide detailed safety and health information, including OSHA 300 Form data for the years 2022-2024, such as man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rate, and any OSHA violations. Contractors must attach OSHA 300 and 300a Forms and provide their six-digit NAICS Code (236220), identify who administers their Safety and Health Program, and disclose their Insurance Experience Modification Rate (EMR).
The associated federal contract opportunity is a solicitation for a project titled "Z1DA--621-24-101 - Renovate B200 Ground For Bronchoscopy," which involves renovating a ground floor bronchoscopy procedure room. The project is being conducted by the Veterans Integrated Service Network 9, with the solicitation number 36C24925R0040. The form is specifically designed to assess a contractor's safety record and environmental performance before potential award of this renovation project.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24925R0040 0003.docx | DOCX document | |
| Attachment 1 Revised Specifications Amendment-0002 - 07-15-2025.pdf | ||
| LIST OF ATTACHMENTS.docx | DOCX document | |
| Attachment 2 Revised Drawings Amendment-0002 - 07-15-2025.pdf | ||
| Attachment 3 Sign-in Sheet - Renovate B200 Ground For Bronchoscopy.pdf | ||
| 36C24925R0040 0002.docx | DOCX document | |
| 36C24925R0040 0001.docx | DOCX document | |
| Attachment 8 Request For Information Form.docx | DOCX document | |
| Attachment 6 Past Performance Questionnaire.docx | DOCX document | |
| 36C24925R0040_1.docx | DOCX document | |
| Attachment 2 Drawings.pdf | ||
| Attachment 1 Specifications.pdf | ||
| Attachment 5 General Condition Breakdown.docx | DOCX document | |
| Attachment 3 Pricing Schedule.xlsx | XLSX spreadsheet | |
| Attachment 9 Wage Determination TN20250160 - Modification 0 - 01-03-2025.pdf | ||
| Attachment 4 Calc. of Self Performed Work General Contractor.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 36C24925R0040
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 .