Attachment - VII - Contractor EMR Certification Form.docx

17 KB Posted

Attached to
Y1DA--Repair Exterior Walls
Solicitation number
36C25022B0026
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 for repairing exterior walls at a Veterans Affairs medical center. The evaluation form requests contact information and safety data from 2018 to the present, including total man hours, OSHA recordable incidents, DART and total case rates, and serious violations. It also asks for the company's NAICS code and who administers its safety program. In addition, it requires copies of OSHA 300 and 300A forms and the company's experience modification rate. The related federal contract opportunity is solicitation number 36C25022B0026 to repair exterior walls at a Veterans Affairs medical center network in an unspecified amount.

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Other files

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36C25022B0026 0002.docx DOCX document
RFI 1.pdf PDF
15-AS402 - BUILDING 15 EAST ELEVATION.pdf PDF
36C25022B0026 0001.docx DOCX document
124-AS404 - BUILDING 124 WEST ELEVATION.pdf PDF
Attachment - III - REPAIR EXTERIOR WALLS DWGS SH 15-21.pdf PDF
Attachment - VIII - RFI Form Solicitaton.docx DOCX document
Attachment - IX - Specifications.pdf PDF
36C25022B0026.docx DOCX document
Attachment - X - Wage Determination.pdf PDF
Attachment - VI - REPAIR EXTERIOR WALLS DWGS SH 36-38.pdf PDF
Attachment - IV - REPAIR EXTERIOR WALLS DWGS SH 22-26.pdf PDF
Attachment - V - REPAIR EXTERIOR WALLS DWGS SH 27-35.pdf PDF
Attachment - II - REPAIR EXTERIOR WALLS DWGS SH 11-14 02.pdf PDF
Attachment - I - REPAIR EXTERIOR WALLS DWGS SH 1-10.pdf PDF
Attachment - II - REPAIR EXTERIOR WALLS DWGS SH 11-14.pdf PDF
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Pre-Award Contractor Safety and Environmental Record Evaluation Form

Information provided below is current and applicable to Project 610-21-208:

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 .