Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24922B0030
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 upgrading a warehouse's fire protection and HVAC systems. The evaluation form requests contractors to provide safety records from the past three years including total man hours, OSHA injury reports, incident rates, and violations. It also asks for NAICS codes, safety program details, and experience modification rates. The related federal opportunity is a solicitation from the Department of Veterans Affairs to completely prepare a site for building operations including demolition and upgrades to fire protection and HVAC systems at a VA medical center warehouse. Contractors are required to furnish all labor, materials, and work to meet drawings and specifications for the project.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C24922B0030 0003.pdf | ||
| 36C24922B0030 0002.pdf | ||
| 36C24922B0030 0001.docx | DOCX document | |
| S04 SITE VISIT CHECK IN Completed.pdf | ||
| General Decision Number TN20220187.pdf | ||
| Final Specs 626A4-21-205.pdf | ||
| Final Drawings 626A4-21-205.pdf | ||
| 36C24922B0030.docx | DOCX document | |
| Calculation of Self Performed Work.docx | DOCX document | |
| RFI Form - Upgrade Warehouse Fire Protection and HVAC.docx | DOCX document |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24922B0030
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: 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 .