Contractor EMR Certification Form 02.docx
DOCX document 27 KB Posted
- Attached to
- Z1DA--Project# 626-21-202 Upgrade Elevator & Main Facility Access Federal contract opportunity
- Solicitation number
- 36C24922B0021
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity for elevator and main facility access upgrades. The evaluation form requests contact information and safety data including OSHA recordable incidents, rates, and violations over the past three years. It also asks for the company's NAICS code, safety program administrator, and experience modification rate. The related federal contract opportunity is solicitation number 36C24922B0021 from the Department of Veterans Affairs for project number 626-21-202 to upgrade elevators and main facility access at a Veterans Health Administration location.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Compiled A _ G Sheets.pdf | ||
| Write-Up 2.pdf | ||
| 36C24922B0021 0004.docx | DOCX document | |
| Structural Addendum 1 S-101 and S-201.pdf | ||
| Write-Up 1.pdf | ||
| C27_Drawings 20-383 Structural Addendum 1.pdf | ||
| 36C24922B0021 0003.docx | DOCX document | |
| Updated Drawings_20-383 Structural Addendum 1.pdf | ||
| Bid Questions - Upgrade Elevator Main Facility Access.pdf | ||
| 36C24922B0021 0002.docx | DOCX document | |
| Write-Up.pdf | ||
| Updated Combined Specs.pdf | ||
| 36C24922B0021 0001.docx | DOCX document | |
| C27_Drawings - 626-21-202 Elevator and Main Facility Access.pdf | ||
| RFI Form 02.docx | DOCX document | |
| DUNS _ TAX ID 02.docx | DOCX document | |
| Wage Rate TVHS-02-25-2022.docx | DOCX document | |
| 36C24922B0021_1.docx | DOCX document | |
| C28_Specs - 626-21-202 Elevator and Main Facility Access.pdf |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24922B0018
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 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: 238210
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 .