Attachment - III - Contractor EMR Certification Form.docx

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Attached to
Y1DA--Remodel Building 3 610A4-21-206
Solicitation number
36C25024B0009
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This document contains a pre-award contractor safety evaluation form and details of a federal contract opportunity for remodeling work at a Veterans Affairs medical center. The pre-award form requests safety-related information from contractors including OSHA recordable incident rates for the past four years, NAICS code, safety program administrator, and experience modification rate. The federal contract opportunity is a solicitation to remodel Building 3 at the VA Northern Indiana Health Care System in Fort Wayne. The project scope involves hazardous material abatement, exterior modifications including new entrance canopies and hardscape, and will be conducted in three phases over 168 days.

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Other files

File Type Posted
36C25024B0009 0001.pdf PDF
Attachment - IV - Wage Determination.pdf PDF
Attachment - V - VHA Directive 1192 01.pdf PDF
Attachment - II - FWVA Remodel Bldg 3 FBD Drawing.pdf PDF
Attachment - I - FWVA Remodel Bldg 3 FBD Specs.pdf PDF
36C25024B0009 Solicitation.pdf PDF

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Pre-Award Contractor Safety and Environmental Record Evaluation Form

Information provided below is current and applicable to Project 610A4-21-206:

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 .