Attachment 7 Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24926R0049
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form required for Solicitation 36C24926R0049, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9 for the "Upgrade Critical Environments I" project. The form is a template designed to collect and verify contractors' occupational safety and health performance data prior to contract award.
The form requires contractors to provide company information and complete a three-year safety record assessment (2023-2025) using OSHA 300 data, including total man hours worked, number of cases involving days away from work or restricted activity, and the Days Away, Restricted, or Transferred (DART) rate calculation. Contractors must also disclose the number of serious, willful, or repeat OSHA violations incurred within the last three years with supporting explanations, provide their six-digit NAICS code (236220 is listed as an example), identify the administrator of their Safety and Health Program, and submit their company's Insurance Experience Modification Rate (EMR). Supporting documentation required includes copies of OSHA 300 and 300a Forms. This form serves as a key evaluation criterion to assess contractor safety compliance and risk management capabilities before contract award.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24926R0049 0001.docx | DOCX document | |
| Sign-in Sheet - 626-25-101 - Upgrade Critical Environments I.pdf | ||
| RFI RESPOSNES - 626-25-101 - Upgrade Critical Environments I.pdf | ||
| Attachment 6 Past Performance Questionnaire.docx | DOCX document | |
| Attachment 4 Calc. of Self Performed Work.xlsx | XLSX spreadsheet | |
| Attachment 3 Pricing Schedule.xlsx | XLSX spreadsheet | |
| Attachment 2 DRAWINGS - FINAL - 03-02-2026.pdf | ||
| Attachment 1 SPECIFCIATIONS - FINAL - 03-02-2026.pdf | ||
| Attachment 8 Request For Information Form.docx | DOCX document | |
| LIST OF ATTACHMENTS.docx | DOCX document | |
| Attachment 9 Wage Determination - TN20260178 - Modification 0 - 01-02-2026.pdf | ||
| Attachment 5 General Condition Breakdown.docx | DOCX document | |
| Attachment 3 Pricing Schedule 02.xlsx | XLSX spreadsheet | |
| Header - List of Attachments.docx | DOCX document | |
| 36C24926R0049_1.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24926R0049
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 .