Attachment - III - Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Attached to
- Z1DA--Remodel Building 114 610-22-518
- Solicitation number
- 36C25022B0034
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity for project 610-22-518 to remodel building 114. The evaluation form requests the contractor's OSHA 300 and 300a forms from 2018 to 2021 with injury rates, as well as details on any serious OSHA violations in the past three years. It also asks for the contractor's NAICS code and who administers its safety and health program. The contractor must provide its insurance experience modification rate. The related federal contract opportunity is solicitation number 36C25022B0034 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10 to remodel the specified building.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25022B0034 0001.docx | DOCX document | |
| 21-100M - 5 of 6 Revised.pdf | ||
| Wage Determination.pdf | ||
| RFI 3.pdf | ||
| RFI 1.pdf | ||
| RFI 2.pdf | ||
| Attachment - IV - Wage Determination.pdf | ||
| Attachment - II - Combined Specs.pdf | ||
| Attachment - I - Combined Drawings.pdf | ||
| 36C25022B0034.docx | DOCX document | |
| Attachment - V - RFI Form Solicitaton.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 Project 610-22-518:
Company Name: Address: Telephone: Fax: Email: Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2018 |
| 2019 |
| 2020 |
| 2021 |
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:
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 .