Contractor EMR Certification Form.docx
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- Solicitation number
- 36C25021B0038
About this file
This document contains a contractor safety and environmental record evaluation form along with details of a related federal contract opportunity for reconfiguration work at a Department of Veterans Affairs medical center. The evaluation form requests the contractor's OSHA 300 and 300a forms from the past three years, North American Industry Classification System code, safety program administrator, and experience modification rate. The related federal contract opportunity posted at SAM.gov seeks bids for renovations to the second floor waiting and check-in areas including constructing a new radiology check-in, reading room, greeter station, and breakroom. The work also involves repurposing various rooms and renovating the existing nuclear medicine area. Bids must be submitted through the posted drawings, specifications, and contract forms including any issued amendments.
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Contractor Safety and Environmental Record Evaluation Form
Company Name: Address: Telephone: Fax: Email: Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2018 |
| 2019 |
| 2020 |
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: 236220
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 .