Contractor EMR Certification Form.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C24923B0014
About this file
This document contains a pre-award contractor safety evaluation form and details of a federal solicitation for installation of a sterile processing supply water filtration system. The evaluation form requests contractor safety information over the past three years including man hours, OSHA recordable incidents, injury rates, and violations. It also asks for North American Industry Classification codes and insurance experience modification rates. The related solicitation seeks a contractor to demolish an existing housekeeping aids closet and install a VERDA sterile processing supply water filtration system at the James H. Quillen VA Medical Center in Mountain Home, Tennessee. The system is intended to service the current capacity of the sterile processing supply facility and meet all applicable codes and standards. The project scope includes commissioning and site cleanup.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24923B0014
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: 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 .