Attachment 7 Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24926R0056
About this file
This is a Pre-Award Contractor Safety and Environmental Record Evaluation Form required for Solicitation 36C24926R0056, a Department of Veterans Affairs Veterans Health Administration project for upgrading an Energy Management System (Project 6264A-18-204).
The form requires prospective contractors to submit comprehensive safety and occupational health data covering three years (2023-2025), including total man hours worked, cases involving days away from work or restricted activity, and the Days Away, Restricted, or Transferred (DART) rate calculated using OSHA's standard methodology. Contractors must also disclose any serious, willful, or repeat OSHA violations within the preceding three years with explanations. Supporting documentation includes completed OSHA 300 and 300a Forms. Additionally, contractors must provide their six-digit NAICS Code (238210 for this acquisition), identify the administrator of their company's Safety and Health Program, and report their Insurance Experience Modification Rate (EMR). This evaluation form serves as a pre-award assessment tool to evaluate contractor safety performance and insurance risk profile prior to contract award.
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Other files
| File | Type | Posted |
|---|---|---|
| RFI RESPONES - 626A4-18-204 - Upgrade Energy Management System.pdf | ||
| Sign-in Sheet - 626A4-18-204 - Upgrade Energy Management System.pdf | ||
| 36C24926R0056 0001.docx | DOCX document | |
| Attachment 5 General Condition Breakdown.docx | DOCX document | |
| Attachment 9 Wage Determination - TN20260187 - Modification 0 - 01-02-2026.pdf | ||
| Attachment 6 Past Performance Questionnaire.docx | DOCX document | |
| Attachment 3 Pricing Schedule.xlsx | XLSX spreadsheet | |
| Attachment A Panel Upgrade List.pdf | ||
| 36C24926R0056_1.docx | DOCX document | |
| Attachment B Bid Item No. 2 Panel Upgrade List.pdf | ||
| Attachment 8 Request For Information Form.docx | DOCX document | |
| Attachment 4 Calc. of Self Performed Work.xlsx | XLSX spreadsheet | |
| Attachment 2 Drawings.pdf | ||
| Attachment 1 Specification.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 36C24926R0056
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: 238210
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 .