Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24921B0018
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 renovating Building 77 to provide customer service. The evaluation form requests the contractor's OSHA 300 forms from 2018 to 2020 detailing man hours, days away from work cases, and DART rates. It also asks for details on serious OSHA violations in the past three years and requires attaching copies of the OSHA 300 and 300a forms. Additional questions cover the contractor's NAICS code, safety program administrator, and experience modification rate. The related federal contract opportunity is solicitation number 36C24921B0018 to renovate Building 77 for customer service through the Department of Veterans Affairs for between $500,000 and $1,000,000.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24921B0018
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 .