Attachment 7 Contractor EMR Certification Form.docx
DOCX document 18 KB Posted
- Solicitation number
- 36C24926R0017
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form (EMR Certification Form) for Solicitation 36C24926R0017 requiring contractors to submit comprehensive occupational safety and health documentation.
Contractors must complete the form by providing three years of OSHA safety data (2022-2024) including total man hours worked, number of cases involving days away from work or restricted activity, DART rates calculated using the standard formula (cases × 200,000 ÷ man hours), and documentation of any serious, willful, or repeat OSHA violations with explanations. Contractors must also submit copies of OSHA 300 and 300A forms, identify their six-digit NAICS code as 236220 (Commercial and Institutional Building Construction), designate the administrator of their Safety and Health Program, and provide their company's Insurance Experience Modification Rate (EMR). This evaluation form applies to the J045--626A4-22-202 AJP-Upgrade Steam Distribution System project at the Tennessee Valley Healthcare System VA Medical Center in Murfreesboro, Tennessee, which involves a 546-calendar-day period of performance for demolition and new construction work including general construction, civil, structural, architectural, mechanical, plumbing, electrical, and low voltage systems. The evaluation is being administered by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation: 36C24926R0017
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 your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 236220 – Commercial and Institutional Building Construction
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 .