Attachment 7 Contractor EMR Certification.docx
DOCX document 16 KB Posted
- Attached to
- Y1DA--596-22-101- Replace Overhead Paging System
- Solicitation number
- 36C24925R0039
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24925R0039, 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 2022-2024, such as man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rates, and any OSHA violations.
The form requests specific documentation including NAICS code (236220), details about the company's Safety and Health Program administrator, and the company's Insurance Experience Modification Rate (EMR). Contractors must attach explanations for any OSHA violations and provide copies of OSHA 300 and 300a Forms. The associated federal contract opportunity involves replacing an obsolete overhead paging system, with the solicitation number Y1DA--596-22-101.
View the file
Other files
Show all 22
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 Solicitation 36C24925R0039
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 .