Contractor EMR Certification Form.docx
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- Solicitation number
- 36C24923B0007
About this file
This solicitation is for restoration services at five historical quarters buildings located at the James H. Quillen VA Medical Center. The scope of work includes replacing wood, installing water barriers, conducting roof repairs, tuckpointing and repairing brick structures, and replacing gutters and downspouts. The period of performance is 400 calendar days. Interested contractors must submit documentation including past safety records, NAICS codes, and insurance rates. The pre-award evaluation form requests details on man-hours, OSHA incident rates, and any safety violations over the past three years. Work is to be completed during normal business hours and must be coordinated to avoid disruptions. The solicitation provides requirements for scheduling, submittals, site visits, deliveries, inspections, and closeout procedures.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation:
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2020 |
| 2021 |
| 2022 |
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: __________________________________
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 .