Attachment - VI - Contractor EMR Certification Form.docx

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Attached to
Replace AHUs and Condensing Units 610A4-21-203
Solicitation number
36C25023B0052
Issued by

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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

File Type Posted
36C25023B0052 Amendment 3.pdf PDF
36C25023B0052 P0002.pdf PDF
Asbestos and Lead Report Ft. Wayne.pdf PDF
36C25023B0052 Amendment 1.pdf PDF
Attachment - V -Wage Determination.pdf PDF
Attachment - IV - RFI Form.doc DOC document
36C25023B0052 IFB.pdf PDF
Attachment - III - Contractor Certification Regarding Safety and Environmental.docx DOCX document
Attachment - I -AHU Drawings.pdf PDF
Attachment - II - Design Firm Specs.pdf PDF

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Pre-Award Contractor Safety and Environmental Record Evaluation Form

Information provided below is current and applicable to Project 610A4-21-203:

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 .