Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24923R0128
About this file
This document contains a pre-award contractor safety and environmental record evaluation form and details of a related federal contract opportunity for design-build renovation services. The evaluation form requests the contractor's OSHA 300 forms and injury rates for the past three years, NAICS code, safety program administrator, and experience modification rate. The related federal opportunity is a solicitation from the Department of Veterans Affairs to design and renovate Building 204 for a SPECT CT electrophysiology cath lab at a VHA facility.
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Other files
| File | Type | Posted |
|---|---|---|
| first site visit sign in sheet.pdf | ||
| second site visit sign in sheet.pdf | ||
| 36C24923R0128 0004.docx | DOCX document | |
| 36C24923R0128 0003.docx | DOCX document | |
| 36C24923R0128 0002.docx | DOCX document | |
| 621-23-101 SOW 6-21-2023.pdf | ||
| 621-23-101 SOW 5-24-2023.pdf | ||
| 36C24923R0128 0001.docx | DOCX document | |
| 36C24923R0128_1.docx | DOCX document | |
| Past Performance Questionnaire.pdf | ||
| DUNS _ TAX ID.docx | DOCX document | |
| 621-23-101 SOW 5-2-2023.pdf | ||
| WD TN20230191 05122023.pdf | ||
| SCA 2015-4641 Rev 19 12272022.pdf |
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Text version
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24923R0128
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 .