Attachment - III - Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Attached to
- Renovate Building 16
- Solicitation number
- 36C25024B0052
About this file
This document is a Pre-Award Contractor Safety and Environmental Record Evaluation Form for a federal contract opportunity. The form requests the company to provide information on their OSHA 300 incident rates, number of OSHA violations, and their Insurance Experience Modification Rate (EMR). The company is also asked to provide their NAICS code and the name of the administrator of their Safety and Health Program.
The related federal contract opportunity is for the Renovation of Building 16 at the Marion VAMC for the VA Northern Indiana Health Care System. The project will involve renovating Building 16 to house the VA Director, Executive Leadership Team, and other major administrative and operational departments. The renovation will be phased to allow circulation between connected Buildings 15 and 17 while Building 16 is unoccupied.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Project 610-20-103:
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 .