Attachment B - EMR Sheet.docx
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- Solicitation number
- 36C26125R0008
About this file
Attachment B is a safety and environmental record certification sheet for a federal contract opportunity (Solicitation Number 36C26125R0008) with the Department of Veterans Affairs Palo Alto Health Care System. The document outlines specific safety requirements for contractors, mandating that to be eligible for contract consideration, contractors must have no more than three serious, or one repeat, or one willful OSHA or EPA violations in the past three years, and maintain an Experience Modification Rate (EMR) of 1.0 or less.
The certification requires contractors to submit a self-certification on company letterhead confirming their safety record and provide documentation from their insurance carrier verifying their current EMR. If an offeror's EMR exceeds 1.0, they must submit a written explanation from their insurance carrier describing the reasons for the higher rate and an anticipated timeline for reducing it. The document includes a table for documenting the number of serious, willful, or repeat violations from OSHA and EPA within the last three years, with space for contractors to attach explanations for any violations.
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Text version
PER VHA DIRECTIVE 7715 (06 April 2017) - SAFETY & ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE (EMR):
Contractor Certification Regarding Project:
To be eligible for consideration and award, the contractor shall have no more than three serious, or one repeat, or one willful OSHA or EPA violation(s) in the past 3 years and have an EMR of equal to or less than 1.0.
All Offerors shall submit the following information pertaining to their past Safety & Environmental Record and EMR with their offer.
1. SAFETY & ENVIRONMENTAL RECORD: A self-certification on company letterhead that the contractor has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years.
2. EMR: All Offerors shall submit information regarding their current EMR. This information shall be obtained from the Offerors’s insurance carrier and be furnished on the insurance carrier’s letterhead. If an Offeror’s EMR is above 1.0, Offeror shall submit a written explanation of the EMR from its insurance carrier furnished on the insurance carrier’s letterhead, describing the reasons for the EMR, and the anticipated date the EMR may be reduced to 1.0 or below.
| 2021 |
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| 2023 |
| 2024 |
Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations. (Four serious, one repeat, or one willful disqualifies the contractor.)
Number of violations from EPA within the last 3 years. Please attach explanation for any violations.
Company’s Current Insurance Experience Modification Rate (EMR) = (Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)
Signature:
Print Name:
File details come from the government source that posted it. Updated .