Contractor EMR Certification Form.docx
DOCX document 27 KB Posted
- Attached to
- Z1DA--621-23-2-5620-0001 - 621-23-109 - Install Lightning Protection & Grounding Systems
- Solicitation number
- 36C24923B0002
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and information on a related federal contract opportunity to install lightning protection and grounding systems. The form requests company identifying information and safety data from OSHA 300 forms for the previous three years, including man hours, cases involving days away from work, DART rates, and serious violations. It also requests the company's NAICS code and details on its safety and health program administrator and insurance EMR. The related federal contract opportunity is solicited by the Department of Veterans Affairs for installing new lightning protection and grounding systems at the James H. Quillen VA Medical Center in Mountain Home, Tennessee.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24923B0002
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 .