Contractor EMR Certification Form.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C24923B0006
About this file
This form requests safety and environmental records from contractors for a Department of Veterans Affairs solicitation to replace an air handling unit. The contractor must provide man hour and injury data from the past three years using OSHA 300 forms, along with explanations for any serious violations. The contractor must also list its six-digit NAICS code for this work as 238210 and identify who administers its safety and health program. In addition, the contractor is asked to disclose its insurance experience modification rate.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24923B0006 0003.docx | DOCX document | |
| 36C24923B0006 0002.docx | DOCX document | |
| 36C24923B0006 0001.docx | DOCX document | |
| COVID Language_Updated 12-14-2021.docx | DOCX document | |
| RFI Form.docx | DOCX document | |
| Drawings_Project_626-20-201 AHU 23.pdf | ||
| Specifications Project_626-20-201 AHU 23.pdf | ||
| DUNS _ TAX ID.docx | DOCX document | |
| Wage Determination TN20220178 12-23-2022.pdf | ||
| 36C24923B0006_2.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 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 .