Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24923B0001
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 and expanding a bulk oxygen delivery system. The evaluation form requests company identifying information and safety data from OSHA 300 forms for the past three years, including man hours, days away from work cases, and serious violations. It also requests the company's NAICS code and details on its safety and health program administration and insurance experience modification rate. The related federal contract opportunity is solicitation number 36C24923B0001 from the Department of Veterans Affairs for project 621-22-104 to upgrade and expand a bulk oxygen delivery system at a Veterans Health Administration facility.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24923B0001 0002.docx | DOCX document | |
| WD_TN20220191 09.02.2022.docx | DOCX document | |
| C28-Specs 621-22-104 Upgrade and Expand Bulk Oxygen Delivery System_100 For Construction.pdf | ||
| COVID Language_Updated 12-14-2021.docx | DOCX document | |
| C27_Drawings 621-22-104 Upgrade and Expand Bulk Oxygen Delivery System 100 For Construction.pdf | ||
| 36C24923B0001_1.docx | DOCX document | |
| RFI Form.docx | DOCX document | |
| DUNS _ TAX ID.docx | DOCX document |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24923B0001
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 .