Attachment - VI - Contractor EMR Certification Form.docx
DOCX document 17 KB Posted
- Attached to
- Replace AHUs and Condensing Units 610A4-21-203 Federal contract opportunity
- Solicitation number
- 36C25023B0052
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity to replace AHUs and condensing units. The evaluation form requests the contractor's company name, address, contact information, OSHA 300 and 300a forms from 2018 to the present, North American Industry Classification System code, and insurance experience modification rate. It seeks details on man hours, days away from work cases, days away from work rate, and any OSHA violations over the past three years. The related federal contract opportunity is issued by the Department of Veterans Affairs Veterans Health Administration with solicitation number 36C25023B0052 to replace AHUs and condensing units for project 610A4-21-203.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25023B0052 Amendment 3.pdf | ||
| 36C25023B0052 P0002.pdf | ||
| Asbestos and Lead Report Ft. Wayne.pdf | ||
| 36C25023B0052 Amendment 1.pdf | ||
| 36C25023B0052 IFB.pdf | ||
| Attachment - III - Contractor Certification Regarding Safety and Environmental.docx | DOCX document | |
| Attachment - IV - RFI Form.doc | DOC document | |
| Attachment - V -Wage Determination.pdf | ||
| Attachment - I -AHU Drawings.pdf | ||
| Attachment - II - Design Firm Specs.pdf |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Project 610A4-21-203:
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 .