Contractor EMR Certification Form.docx
DOCX document 27 KB Posted
- Attached to
- Y1DA--626A4-CSI-105 DB Prepare Site for York MRI
- Solicitation number
- 36C24922R0066
About this file
This form requests safety and environmental records from contractors interested in solicitation number 36C24922R0066 for preparing the site of a magnetic resonance imaging facility at the Alvin C. York Campus of the Department of Veterans Affairs. The contractor must provide man-hours and injury rates for 2019-2021 using OSHA 300 forms, explain any serious violations over the past three years, and attach the OSHA forms and their NAICS code. The contractor must also disclose their experience modification rate for insurance and the administrator of their safety and health program.
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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 .