Contractor EMR Certification Form.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C24923B0017
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 replacing air handling units at a Veterans Affairs medical center. The evaluation form requests the contractor's OSHA 300 forms from 2019 to 2021 detailing man hours, cases involving days away from work or restricted activity, and days away restricted or transferred rate. It also asks for details on serious, willful, or repeat OSHA violations in the last three years. The contractor must provide its six-digit NAICS code, administrator of its safety and health program, and insurance experience modification rate. The related federal contract opportunity is issued by the Veterans Health Administration Veterans Integrated Service Network 9 to replace air handling units 7 and 19 and upgrade or replace units 3B and 53 at a Veterans Affairs medical center.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C24923B0017 0001.docx | DOCX document | |
| UEI _ TAX ID.docx | DOCX document | |
| P07_Wage Determination_TN20230178 04-21-2023.pdf | ||
| 36C24923B0017_1.docx | DOCX document | |
| C27_Construction Drawings - Replace Air Handling Units 7 and 9.pdf | ||
| C28_626-19-202 AHU 3B and 53 Specs.pdf | ||
| RFI Form.docx | DOCX document | |
| C28_Specifications-Replace Air Handling Units 7 and 9.pdf | ||
| C27_626-19-202 AHU 3B and 53 Drawings.pdf |
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 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 .