Contractor EMR Certification Form.docx
DOCX document 27 KB Posted
- Solicitation number
- 36C24923R0030
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 renovation work. The form requests a contractor's OSHA 300 forms and insurance experience modification rate. It also asks for the contractor's NAICS code, number of man hours and safety incidents over the past three years, and who administers its safety and health program. The related federal contract opportunity is solicitation number 36C24923R0030 from the Department of Veterans Affairs to renovate the D Wing of Building 200 at the James H. Quillen VAMC in Mountain Home, Tennessee to create an isolation ward.
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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 .