Attachment 7 Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Solicitation number
- 36C24926R0013
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form required for solicitation 36C24926R0013, which concerns the replacement of site underground chilled water piping for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. Contractors must provide comprehensive safety and environmental compliance documentation including company contact information, OSHA 300 and 300A forms for calendar years 2023, 2024, and 2025, and detailed metrics on man hours, cases involving days away from work or restricted activity, and DART rates. The form requires contractors to report the number of serious, willful, or repeat OSHA violations from the preceding three years with attached explanations for any violations, identify their six-digit NAICS code (236220), designate the individual responsible for administering the company's Safety and Health Program, and provide their Experience Modification Rate (EMR) from their insurance carrier.
This template serves as a pre-award evaluation tool to assess contractor safety performance and environmental compliance prior to contract award. Contractors must complete all requested fields, attach supporting documentation from OSHA publications, and demonstrate their safety record management capabilities as part of the proposal submission requirements for this federal construction solicitation.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C24926R0013 0003.docx | DOCX document | |
| 621-22-108 - Replace Site Underground Chilled Water Piping _ RFI Updated Responses 3-5-2026.pdf | ||
| 13.09_4_119-M100 Layout1_Revised.pdf | ||
| 13.08_4_119-MD100 Layout1_Revised.pdf | ||
| 621-22-108 - Replace Site Underground Chilled Water Piping _ RFI Responses.pdf | ||
| 36C24926R0013 0002.docx | DOCX document | |
| Project 621-22-108 _ Pre-Bid Sign-In Sheet - 02-13-2026.pdf | ||
| 36C24926R0013 0001.docx | DOCX document | |
| Attachment 6 Past Performance Questionnaire.docx | DOCX document | |
| Attachment 5 General Condition Breakdown.docx | DOCX document | |
| Attachment 4 Calc. of Self Performed Work.xlsx | XLSX spreadsheet | |
| Attachment 2 Drawings.pdf | ||
| 36C24926R0013_1.docx | DOCX document | |
| Attachment 8 Request For Information Form.docx | DOCX document | |
| Attachment 9 Wage Determination - TN20250191 - Modification 0 - 01-02-2026.pdf | ||
| Attachment 3 Pricing Schedule.xlsx | XLSX spreadsheet | |
| Attachment 1 Specifications.pdf |
Show all 17
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 36C24926R0013
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 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 .