Contractor EMR Certification Form.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24923B0015
About this file
This form requests safety and insurance information from contractors in preparation for the solicitation numbered 36C24923B0015 to upgrade mixing valves, faucets, and showers at the Nashville VA Medical Center. The contractor is asked to provide man-hours and OSHA recordable incident rates for the past three years, attach copies of OSHA forms 300 and 300A, and state their North American Industry Classification System code and insurance experience modification rate. The administer of the company's safety program and current insurance EMR are also requested.
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Other files
| File | Type | Posted |
|---|---|---|
| 626-22-203 Mixing Valves Faucets and Showers SOW Final 07.07.2023.pdf | ||
| 224000 Plumbing Fixtures 07.07.2023.pdf | ||
| 36C24923B0015 0004.docx | DOCX document | |
| RFI Answers Final.pdf | ||
| 36C24923B0015 0003.docx | DOCX document | |
| 36C24923B0015 0002.docx | DOCX document | |
| 36C24923B0015 0002 626-22-203 Upgrade Mixing Valves Faucets and Showers Site Visit Sign In Sheet.pdf | ||
| 36C24923B0015 0001.docx | DOCX document | |
| 36C24923B0015 06012023.docx | DOCX document | |
| RFI Form.docx | DOCX document | |
| Copy of Nashville Campus - 626-22-203 Work and Locations.pdf | ||
| UEI _ TAX ID.docx | DOCX document | |
| 626-22-203 Specs Upgrade Valves Faucets and Shower.pdf | ||
| General Decision Number TN20230178 05122023.pdf | ||
| BIOCIDE INJECTION PORT DETAIL.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 36C24923B0015
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: 238220
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 .