Attachment 9 - Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Attached to
- 7G21--621-22-704 - EHRM NextGen Wifi Upgrade Federal contract opportunity
- Solicitation number
- 36C24924R0067
About this file
This document is the Attachment 9 - Contractor EMR Certification Form for Solicitation 36C24924R0018. It requires the contractor to provide information about their safety and environmental record, including OSHA 300 form data, number of OSHA violations, and their Insurance Experience Modification Rate (EMR). The required NAICS code is 238220. The document requests the contractor to identify the administrator of their safety and health program. This information is being collected as part of the pre-award evaluation of the contractor's safety and environmental record for the federal contract opportunity 36C24924R0067, which is for the EHRM NextGen Wi-Fi Upgrade project for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9.
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24924R0018
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2020 |
| 2021 |
| 2022 |
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: 238220
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 .