Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24922B0003
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 renovate bathrooms. The evaluation form requests the contractor's OSHA 300 forms from 2018 to 2020 detailing man hours, cases involving days away from work or restricted activity, days away restricted or transferred rate, and any serious, willful or repeat OSHA violations. It also asks for the contractor's six-digit NAICS code, who administers their safety and health program, and insurance experience modification rate. The related federal contract opportunity is solicitation number 36C24922B0003 to renovate bathrooms for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9, with a magnitude of construction between $500,000 and $1,000,000.
View the file
Other files
Show all 20
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 36C24922B0003
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 .