Attachment 7 Contractor EMR Certification.docx
DOCX document 16 KB Posted
- Attached to
- Y1DA--596-20-104 - Refinish Connecting Corridors
- Solicitation number
- 36C24925R0063
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for Solicitation 36C24925R0063, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The form requires contractors to provide detailed safety performance metrics, including OSHA 300 form data for 2022-2024, covering man hours, workplace injury cases, DART (Days Away, Restricted, or Transferred) rates, and OSHA violations.
Contractors must submit documentation including OSHA 300 and 300a forms, provide their six-digit NAICS code (236220 for this acquisition), identify who administers their Safety and Health Program, and disclose their Company's Insurance Experience Modification Rate (EMR). The form is part of a solicitation for a project titled "Y1DA--596-20-104 - Refinish Connecting Corridors", which appears to involve renovation or maintenance work for a Veterans Affairs facility.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24925R0063 0002.docx | DOCX document | |
| Attachment 1 _ RFI Responses - 10-01-2025.pdf | ||
| Attachment 3 - VHA COR Contractor Security Presentation June 2025 Final.pdf | ||
| Attachment 2- RFI - Responses.pdf | ||
| Attachment 1 - Pre-Bid Sign-in Sheet - 09-15-2025.pdf | ||
| 36C24925R0063 0001.docx | DOCX document | |
| Attachment 8 Request For Information Form.docx | DOCX document | |
| Attachment 9 Past Performance Questionnaire.docx | DOCX document | |
| Attachment 5 Calc. of Self Performed Work General Contractor.xlsx | XLSX spreadsheet | |
| Attachement 1 Specifications - VOL. I.pdf | ||
| 36C24925R0063_1.docx | DOCX document | |
| Attachment 6 General Condition Breakdown.docx | DOCX document | |
| Attachement 2 Specifications - VOL. II.pdf | ||
| Attachment 3 Drawings.pdf | ||
| Attachment 4 Pricing Schedule.xlsx | XLSX spreadsheet | |
| Attachment 10 Wage Determination - KY20250090 - Modification 7 - 08-08-2025 02.pdf |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24925R0063
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 .